Apprenticeship Agreement - New York
Please send to your regional DOL office:
Apprenticeship Agreement
Sponsor No.
ATP Code
I. Apprenticeship Agreement
Name of Apprentice (Last, First, M.I.)
Social Security Number
1. Name of Program Sponsor
Address of Apprentice (no. and street)
Physical address of Program Sponsor (no. and street)
City County State Zip code
City County State Zip code
Answer both A and B
A. Ethnic Group Hispanic or Latino Not Hispanic or Latino
B. Race White Asian
Black/African American American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
Mailing address of Program Sponsor (no. and street)
City County State Zip code
Sex
M
F
Veteran
Yes
No
Home & Cell phone numbers
H
C
Birth date
2. Trade: Time-based Competency-based Hybrid
E-mail address
Has the apprentice received any Certificate of Completion from a State or Federal
Apprenticeship Program? Yes No
If “Yes,” Trade State
3.Start Date
4. Length of program
(Months)
5. DOL Apprentice Probation
Period for Completion Rates
(Months)
6. Related and Supplemental Instruction (RI) Provider(s) and location(s)
RI Compensated
Yes
No
7. Minimum Journey-Worker Rate
8.Credit for previous training or experience:
Months Points Sections
Reinstatement Vocational Education Transfer Previous Experience (Employer name):
9. Apprentice Wage Progression (Without Benefits) for each Period. Choose one: Months Hours Points Sections
1 2 3 4 5 6 7 8 9 10
The Sponsor and the Apprentice Agree to the Terms on Page 2 of this Form.
/ / / /
Signature of Apprentice and Parent/Guardian if age 16-17 Date Signature of Official Sponsor Representative Date
Registered by the New York State Department of Labor:
/ /
Signature New York State Department of Labor Date
THE DEPARTMENT OF LABOR MUST RECEIVE THIS AGREEMENT WITHIN 30 CALENDAR DAYS OF THE REQUESTED START DATE.
II. Worksite Training Completion or Termination
Check one: Completed Worksite Training Terminated for Cause Quit Layoff Program Termination Transfer
(Explain in Comments) (Lack of Work)
Completion or Termination Date
Comments
/ /
Signature of Official Sponsor Representative Date Print Name
THE DEPARTMENT OF LABOR MUST RECEIVE THIS FORM WITHIN 30 CALENDAR DAYS OF THE COMPLETION/TERMINATION DATE.
STATE USE ONLY
III. RI Completion
Apprentice has satisfied the RI requirements. Completion date:
Apprentice has not satisfied the RI requirements.
/ /
Signature of DLEA Representative Date Print Name
AT 401 (09/16) Must be returned within 30 days of receipt Page 1 of 2
State Use Only
Date Init.
To ATC
To DLEA
Rank Verify
Data Entry
State Use Only
Date Init.
To ATC
To DLEA
Data Entry
State Use Only
Date Init.
To ATC
To DLEA
Data Entry
Page 1/2
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