Fillable Printable Apprenticeship Agreement - New York
Fillable Printable Apprenticeship Agreement - New York
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
Apprenticeship Agreement Terms
1. The program Sponsor agrees:
a. To employ the Apprentice to learn the craft or trade described above. Training and employment must conform to the terms
and conditions for this trade in the Sponsor's registered program.
b. That equal opportunity applies to all phases of apprenticeship employment and training. There will be no discrimination
because of race, creed, color, religion, national origin, age, sex, disability, veteran status, marital status, or arrest record.
c. To give reasonable notice to the Apprentice of any proposed adverse action, unless the collective bargaining agreement
provides for another process. Layoff for lack of work does not require an advance notice.
2. The Apprentice agrees:
a. To perform diligently and faithfully the work of the trade or craft as presented in the terms and conditions of this program and
as outlined in the Work Processes.
b. To maintain a record documenting task rotation.
i. The Sponsor agrees to ensure compliance.
c. To complete or fulfill a minimum of 144 hours of Related and Supplemental Instruction (RI) per year.
i. Participation in RI is mandatory.
d. That the Sponsor may arrange for the Intra-Program transfer of the Apprentice from one signatory employer to another. This
is to ensure training and reasonably continuous employment.
3. The Apprentice and Sponsor agree:
a. That the Apprentice has not completed a State/Federal Apprenticeship Program (excluding the Department of Correctional
Services) for the trade of indenture or a related trade.
b. To comply with the State Labor Law and applicable Regulations, including promptly providing reports and information.
c. That a Sponsor that cannot fulfill the obligations under the apprenticeship agreement may (with the consent of the Apprentice)
transfer the agreement to another Sponsor of a registered program. The Labor Commissioner must receive written notice of
the transfer. The Apprentice must receive full credit for the satisfactory period of the served apprenticeship.
d. That the Apprentice is not registered until this form is signed by the authorized New York State Department of Labor
representative.
4. During the Department of Labor (DOL) Apprentice Probation Period, the Sponsor or the Apprentice may cancel this agreement without
adverse impact on the program’s completion rate, however Apprentice turnover may be considered when reviewing the quality of a
program’s performance.
5. After the DOL Apprentice Probation Period:
a. This agreement may be cancelled at the request of the Apprentice.
b. The Sponsor may suspend or cancel for good cause. The Apprentice must receive proper notice and must have a reasonable
opportunity for corrective action. There must be written notice to the Apprentice and the Department of the final action taken.
6. If a controversy grows from this agreement, it may be submitted to the Apprentice Training Office listed on the front if it is not settled
locally or covered by a collective bargaining agreement.
Instructions
I. Apprenticeship Agreement
1. Sponsor Information Block: Enter information as it appears on the Apprentice Training Program Registration Agreement, (AT 10).
2. Trade: Enter the name of the trade the Apprentice will be trained in, as it appears on the AT 10. Indicate the Training Approach.
3. Start Date (Leave blank if submitting with new program application): Enter the requested start date of the proposed Apprentice.
The Apprentice and Sponsor representative must sign the form either prior to, or on the Apprentice's start date. (Must be received by
DOL within 30 days of the start date).
4. Length of Program: Enter the term (in months) of the program.
5. DOL Apprentice Probation Period for Completion Rates: Enter, in months, 25% of the length of the program, or one year, whatever
is shorter.
6. RI: Enter the official name of provider and geographic location. Indicate if the Apprentice is compensated while attending RI.
7. Minimum Journeyworker Rate: Enter Journeyworker rate as it appears on the AT 10.
8. Credit for Previous Training or Experience: When giving credit to an Apprentice, check the correct box, enter the credit in months
or points/sections and include a letter of justification. This must have dates, names of previous employers, and a description of the
credit acquired.
9. Apprentice Wage Progression: Enter the wage rate schedule for the trade as shown on the AT 10.
Signatures: This form must be signed by the Apprentice, Apprentice’s parent/guardian (if applicable), and Sponsor representatives.
After signing, immediately send it to the Apprentice Training Office indicated in the upper right corner.
II. Worksite Training Completion or Termination
1. Completion/Termination: Check the correct box.
a. Completed Worksite Training: The Apprentice has satisfactorily completed worksite training.
b. Terminated for Cause: The Apprentice was terminated for cause. Explain in comments section. Examples: Failure to
attend/complete RI; Apprentice misconduct; Failure to maintain proper records; Unable to perform duties.
c. Quit: The Apprentice terminated training by resignation.
d. Layoff (Lack of Work): The Apprentice was terminated from training by layoff due to lack of work.
e. Program Termination: The Apprentice was terminated from training because the program was terminated/deregistered.
f. Transfer: The Apprentice is transferred between programs in the same trade. The Apprentice and Sponsors are all in
agreement, and the Apprentice is provided with a transcript of RI and On-The-Job Training by the transferring Sponsor.
2. Completion or Termination Date: Enter the exact date the Apprentice completed or was terminated.
3. Signature: The official Sponsor representative must sign and date this form.
AT 401 (09/16) Page 2 of 2
