1. Customer and Certification

Applicant’s Name: / Application Date: // / Waiver/ In-Training Date: // / TWIST ID #:
Petition #: / Trade Act of 1974 2002 2009 2011 / State:

2. Reemployment Information

The applicant’s Average Weekly Wage (AWW):
Are there jobs available in applicant’s normal commuting area, using this applicant’s existing job skills, and paying at least
$(80% of AWW)? Yes No
Is the applicant willing to relocate? Yes No If so, where?
Provided labor market information (LMI) data: Yes No
www.tracer2.com socrates.cdr.state.tx.us www.careeronestop.org www.myskillsmyfuture.org Other
Occupational interests:

3. Goals (based on initial and/or complete assessment)

Current occupational skills:
Specific occupational goal:
Minimum education level generally required for this occupation:
Degree, license, or certification required for this position:
Expected occupational wage:
Assessment type and scores:
Was a waiver issued? If yes, list reason and date.

4. Training Program

Occupation: / Date of Training Request: //
Is this occupation licensed? Yes No; If a licensed occupation, does applicant have a conviction history? Yes No
If conviction exists, has licensing authority issued a preliminary evaluation of license eligibility for the applicant? Yes No
Training program requires: Remedial (ESL, GED, Developmental) Prerequisites
Is the length of training within the allowable TAA regulations? Yes No / Remedial weeks in training: / Prerequisite weeks in training: / Total weeks of training:
Is the training program full time? Yes No / Training includes self-financing: Yes No

Training Institution Information (only institutions worker will actually attend)

Name of Training Institution 1:
Street Address:
City: / State: / Zip:
Training Period: // -- // / Number of training days per week:
Course/Program Name: / Is the training full time? Yes No
Approved by Texas Education Agency (TEA), Texas Higher Education Coordinating Board, Texas Workforce Commission (TWC), or regulated by an accredited board? Yes No
Has the training provider accepted the trade-affected worker into the proposed training program? Yes No
Is the training facility outside the local commuting area? Yes No
If yes, are there training providers within the local commuting area? Yes No
Name of Training Institution 2:
Street Address:
City: / State: / Zip:
Training Period: // -- // / Number of training days per week:
Course/Program Name: / Is the training full time? Yes No
Approved by TEA, Texas Higher Education Coordinating Board, TWC, or regulated by an accredited board? Yes No
Has the training provider accepted the trade-affected worker into the proposed training program? Yes No
Is the training facility outside the local commuting area? Yes No
If yes, are there training providers within the local commuting area? Yes No
Name of Training Institution 3:
Street Address:
City: / State: / Zip:
Training Period: // -- // / Number of training days per week:
Course/Program Name: / Is the training full time? Yes No
Approved by TEA, Texas Higher Education Coordinating Board, TWC, or regulated by an accredited board? Yes No
Has the training provider accepted the trade-affected worker into the proposed training program? Yes No
Is the training facility outside the local commuting area? Yes No
If yes, are there training providers within the local commuting area? Yes No

5. Transportation and Subsistence Payment Calculation

Is the distance from the applicant’s home to training facility greater than 50 miles? Yes No
Commuting Distance (round-trip):
Federal mileage rate from www.gsa.gov:
Total Commute Mileage Rate (distance X mileage rate): / miles
$.555 / mile
(effective 4/17/12) / Daily Lodging Expense (excluding taxes):
Estimated Daily Meals:
Estimated Daily Subsistence Expense (lodging + meals):
OR
50% of per diem rate www.gsa.gov: / $$
$
$
Daily Mileage Cost: $ / Daily Subsistence Rate (most cost-effective method): $
Total Transportation/Subsistence Cost (Weekly Transportation/Subsistence X # of weeks): $
Is the customer staying at the training facility? Yes No If yes, single round-trip transportation expense applies.
(Only one round-trip payment is allowed under the TAA program if the customer is staying at the training site.)
Privately Owned Vehicle:
Public/Mass Transit:
Other: / $
$
$ / Payment for trip to training institution: $ Training Start Date: //
Payment for trip from training institution: $ Training End Date: //
Total round-trip: $
Total Cost of Transportation/Subsistence Payment: $

6. Cost of Training

Category / TAA Funding Institution 1 / TAA Funding Institution 2 / TAA Funding Institution 3 / Total
TAA Funding / Other
Funding / Other Funding Sources
Tuition
Fees
Training-Required Supplies
Books
Uniforms
Transportation/Subsistence Cost
License Fee
Test Fee
Other (identify): / $
$
$
$
$
$
$
$
$ / $
$
$
$
$
$
$
$
$ / $
$
$
$
$
$
$
$
$ / $
$
$
$
$
$
$
$
$ / $
$
$
$
$
$
$
$
$
Total Costs / $ / $ / $ / $ / $
Total Training Costs (all institutions and funding sources): $
Does the total cost of the TAA-funded training exceed the reasonable cost standard?* Yes No

*If yes, mark approval criterion #6 (Reasonable Cost) “No” and forward to the TAA state office for review and approval.


7. Training Justification

1.  Suitable employment is unavailable. / Yes No
2. The worker will benefit from appropriate training. / Yes No
3. There is a reasonable expectation of employment following completion of training. / Yes No
4.  The training is reasonably available from a private or public school regulated by a state agency. / Yes No
5. The worker is qualified to undertake and complete the training. / Yes No
6. The training is available at both a reasonable cost and the lowest cost available for the occupation.
If no, justification approved by TWC Trade Services. / Yes No
Additional Considerations:
1.  Training program can be completed within statutory limitations (104/130/156 weeks, depending on petition). / Yes No
2.  Self-financing of required training costs is not required of customer. / Yes No
3.  If petition is under 70,000, training is full time; if petition is over 70,000, training can be part time without Trade Readjustment Assistance (TRA). / Yes No
The worker has been informed of the following:
The potential wage or salary of the selected occupation.
The training program must be amended and approved prior to any changes in the curriculum or
sequence of courses.
The worker must inform his or her case manager immediately if he or she withdraws from training or courses.
The worker must submit grades/transcript to his or her case manager at the end of each semester.
The worker must provide his or her case manager the Instructor Attestation form every days, indicating progress made.
Completion of the Reemployment and Training Plan (Plan) is scheduled for ; the worker must notify his or her case manager immediately if the worker falls behind schedule or wishes to change the sequence of courses on his or her degree plan.
The worker is expected to meet all listed benchmarks contained in this Plan.
Failure to achieve benchmarks on two occasions can result in denial of Completion TRA (if applicable)
or termination of this Plan.
TRA cannot be paid for breaks in training of more than 30 days.
TRA cannot be paid for part-time training, self-study, or test preparation.
TRA payment for the entire duration of training is not assured. The worker must have sufficient financial
resources to continue training for periods when TRA is not paid.
Trade Adjustment Assistance (TAA) training benefits provide for one training/certification/degree per TAA
eligibility. The information contained in this Plan reflects this one training/certification/degree.
Signature (Worker): / Date: //
Signature (Workforce Solutions Office Representative): / Date: //
Under TAA regulations, training is: approved, or forwarded to TAA state office and recommended for approval or recommended for denial.
Curriculum Outline / Benchmark Tracking
Semester/Time Frame Year / Must be evaluated at intervals of no more than 60 days.
Date of Benchmark Review / Type of Documentation to Verify Progress / Good
Academic Standing / Training Will Be Completed by Approved Time Frame / Warning
Issued / Date REP
Modified/
Amended
(if applicable)
Course # / Course/Program Title / Credit
Hour / Final Grade
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Final Grades/Transcript/ Remedial levels reviewed and in file? / Yes No / Remedial Level:
Part Time Full Time / Total Credit Hours: / Date Grades/Transcript/ Remedial levels received: / //
Curriculum Outline / Benchmark Tracking
Semester/Time Frame Year / Must be evaluated at intervals of no more than 60 days.
Date of Benchmark Review / Type of Documentation to Verify Progress / Good
Academic Standing / Training Will Be Completed by Approved Time Frame / Warning
Issued / Date REP
Modified/
Amended
(if applicable)
Course # / Course/Program Title / Credit
Hour / Final Grade
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Final Grades/Transcript/ Remedial levels reviewed and in file? / Yes No / Remedial Level:
Part Time Full Time / Total Credit Hours: / Date Grades/Transcript/ Remedial levels received: / //
Curriculum Outline / Benchmark Tracking
Semester/Time Frame Year / Must be evaluated at intervals of no more than 60 days.
Date of Benchmark Review / Type of Documentation to Verify Progress / Good
Academic Standing / Training Will Be Completed by Approved Time Frame / Warning
Issued / Date REP
Modified/
Amended
(if applicable)
Course # / Course/Program Title / Credit
Hour / Final Grade
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Final Grades/Transcript/ Remedial levels reviewed and in file? / Yes No / Remedial Level:
Part Time Full Time / Total Credit Hours: / Date Grades/Transcript/ Remedial levels received: / //
Curriculum Outline / Benchmark Tracking
Semester/Time Frame Year / Must be evaluated at intervals of no more than 60 days.
Date of Benchmark Review / Type of Documentation to Verify Progress / Good
Academic Standing / Training Will Be Completed by Approved Time Frame / Warning
Issued / Date REP
Modified/
Amended
(if applicable)
Course # / Course/Program Title / Credit
Hour / Final Grade
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Final Grades/Transcript/ Remedial levels reviewed and in file? / Yes No / Remedial Level:
Part Time Full Time / Total Credit Hours: / Date Grades/Transcript/ Remedial levels received: / //
Curriculum Outline / Benchmark Tracking
Semester/Time Frame Year / Must be evaluated at intervals of no more than 60 days.
Date of Benchmark Review / Type of Documentation to Verify Progress / Good
Academic Standing / Training Will Be Completed by Approved Time Frame / Warning
Issued / Date REP
Modified/
Amended
(if applicable)
Course # / Course/Program Title / Credit
Hour / Final Grade
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Final Grades/Transcript/ Remedial levels reviewed and in file? / Yes No / Remedial Level:
Part Time Full Time / Total Credit Hours: / Date Grades/Transcript/ Remedial levels received: / //
Curriculum Outline / Benchmark Tracking
Semester/Time Frame Year / Must be evaluated at intervals of no more than 60 days.
Date of Benchmark Review / Type of Documentation to Verify Progress / Good
Academic Standing / Training Will Be Completed by Approved Time Frame / Warning
Issued / Date REP
Modified/
Amended
(if applicable)
Course # / Course/Program Title / Credit
Hour / Final Grade
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Final Grades/Transcript/ Remedial levels reviewed and in file? / Yes No / Remedial Level:
Part Time Full Time / Total Credit Hours: / Date Grades/Transcript/ Remedial levels received: / //
Curriculum Outline / Benchmark Tracking
Semester/Time Frame Year / Must be evaluated at intervals of no more than 60 days.
Date of Benchmark Review / Type of Documentation to Verify Progress / Good
Academic Standing / Training Will Be Completed by Approved Time Frame / Warning
Issued / Date REP
Modified/
Amended
(if applicable)
Course # / Course/Program Title / Credit
Hour / Final Grade
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Final Grades/Transcript/ Remedial levels reviewed and in file? / Yes No / Remedial Level:
Part Time Full Time / Total Credit Hours: / Date Grades/Transcript/ Remedial levels received: / //
Curriculum Outline / Benchmark Tracking
Semester/Time Frame Year / Must be evaluated at intervals of no more than 60 days.
Date of Benchmark Review / Type of Documentation to Verify Progress / Good
Academic Standing / Training Will Be Completed by Approved Time Frame / Warning
Issued / Date REP
Modified/
Amended
(if applicable)
Course # / Course/Program Title / Credit
Hour / Final Grade
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Final Grades/Transcript/ Remedial levels reviewed and in file? / Yes No / Remedial Level:
Part Time Full Time / Total Credit Hours: / Date Grades/Transcript/ Remedial levels received: / //
Curriculum Outline / Benchmark Tracking
Semester/Time Frame Year / Must be evaluated at intervals of no more than 60 days.
Date of Benchmark Review / Type of Documentation to Verify Progress / Good
Academic Standing / Training Will Be Completed by Approved Time Frame / Warning
Issued / Date REP
Modified/
Amended
(if applicable)
Course # / Course/Program Title / Credit
Hour / Final Grade
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Yes
No / Yes
No
Final Grades/Transcript/ Remedial levels reviewed and in file? / Yes No / Remedial Level:
Part Time Full Time / Total Credit Hours: / Date Grades/Transcript/ Remedial levels received: / //

Required Books and Supplies (To be covered by TAA funding, the following required books, tools, and supplies must be purchased by every student enrolled in these courses.)