Date: _______________________

WEST VIRGINIA WORKFORCE DEVELOPMENT
REQUEST FOR TRAINING INTAKE FORM
Contact information:

Organization name: ______________________________________________________________________________

Contact name: ___________________________________ Title: _________________________________________

Address: ________________________________________________________________________________________

City ________________________________________ State: ____________________ ZIP: ____________________

West Virginia county: ______________________________ Telephone number: ______________________________

Fax: _________________________ Email: __________________________ Website: __________________________

Company background:

_____ Manufacturing _____ Service _____ Retail _____ Technology _____ Other (specify) ______________________

Company status

______ New ______ Existing ______ Expansion ______ Retention

Primary product/service: _______________________________________________________________

Number of years operating in W.Va. __________ No. of facilities in W.Va. ___________ Total facilities ___________

If your headquarters/ownership is not located in West Virginia, list state/country: ______________________________

Are you a ______ for-profit ______ not-for-profit organization? Other (specify) ________________________________

Workforce information:

Total number of company employees: ____________________

(If multiple facilities, provide breakdown in Other Comments section below)

Average entry-level wage: Salary ______________________________ Hourly ______________________________

Average company wage: Salary ________________________________ Hourly ______________________________

Average hourly value of health benefits provided by company, if applicable: ________________________________

Have any employees been laid off in the past 12 months? Yes _____ No _____

Net new job growth (previous 6 months and future 12 months): Full time _______________ Part time _______________

Has your company utilized WORKFORCE WV centers? Yes _____ No _____

If yes, briefly describe services received:

____________________________________________________________________________________________________

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WEST VIRGINIA WORKFORCE DEVELOPMENT
REQUEST FOR TRAINING INTAKE FORM PAGE 2
Training needs:

Nature of training plans proposed (type, purpose, position):

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

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Number of employees to be trained: _______________

Of these, how many are recent hires (e.g., past six months?) __________

How many of these employees reside in West Virginia? __________

Describe what other, if any, local, state or federally funded training programs your company participated in over the past two years, including dollar amounts.

____________________________________________________________________________________________________

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____________________________________________________________________________________________________

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Other comments:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

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Please submit this form to the attention of:
Jeanna Moore, manager, Workforce Development Direct Services
Governor's Workforce Investment Division, West Virginia Development Office
Building 6, Room 617
Capitol Complex
Charleston, WV 25305-0311
(877) 967-5498 Fax: (304) 558-7029
jmoore@wvdo.org