UI / DE 4365TP

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

EDD Phone Numbers:
English:
1-800-300-5616
Spanish:
1-800-326-8937
Mandarin:
1-866-303-0706
Vietnamese:
1-800-547-2058
Cantonese:
1-800-547-3506
TTY (nonvoice):
1-800-815-9387

TRAINING PROVIDER QUESTIONNAIRE

Student Name:
Blank line  

STUDENT INSTRUCTIONS

You must have your training provider, authorizing program, or union representative complete this questionnaire as proof of your enrollment and validation of the information you provided on the California Training Benefits (CTB) Application and School Or Training Questionnaire, DE 4365TQ. You must complete and return both the application and this questionnaire within ten (10) calendar days of the mail date of this notice to the Employment Development Department (EDD) as instructed in the Notice of Request for School or Training Information, DE 4365T.
Provide the enclosed Training Provider Letter, DE 3100D, to your training provider to authorize the release of your school or training information to the EDD. Do not return the Training Provider Letter to the EDD. Your training provider must keep the Training Provider Letter for their records.

TRAINING PROVIDER, TRAINING PROGRAM, OR UNION REPRESENTATIVE INSTRUCTIONS

Please complete this questionnaire for the student named above and return the completed and signed form to the student. The term “training program” refers to both vocational training programs and degree programs. The information you provide will be used to validate the training information provided to the EDD by the student. This information is also used to determine the student’s availability for work and eligibility to receive unemployment insurance (UI) benefits under the California Training Benefits (CTB) program while attending training.

SECTION A - SCHOOL OR TRAINING PROGRAM

  1. Name of the student's school or training facility:
    Blank line 
  2. School or training facility location:
    Street Address:
    Blank line  
    City:
    Blank line  
    County:
    Blank line  
    State:
    Blank line  
    ZIP:
    Blank line  
  3. What is the student's training program or course of study?
    Blank line  
  4. Is the student’s training provider and specific training program listed on California’s Eligible Training Provider List (ETPL)?
  5. What industry related license, credential, or certification will the student receive after completing the training program, if any?
    Blank line 
  6. What type of work or specific occupation will the student be qualified to perform after completing the training program?
    Blank line 
  7. What date did the student first begin attending the training program?
    MM/DD/YYYY
  8. What date is the student expected to complete the entire training program, including any intern/externships?
    MM/DD/YYYY
  9. How many credits/units/hours is the student currently taking?
  10. How many credits/units/hours does the student need in order to complete the training program?
  11. Is the student’s school or training attendance considered full-time?
  12. Does the training program offer a summer session or classes during the months of June, July, and/or August?
    1. Will the student attend the next summer session?
    2. What are start and end dates of the next summer recess?
      MM/DD/YYYY to MM/DD/YYYY
  13. What are the start and end dates of any scheduled recess periods, breaks, or summer recesses that will occur during the student’s school or training period? (A school calendar may also be provided.)
    Blank line 
    Blank line 
 

Form Tracking:

DE 4365TP Rev. 5 (10-15) (INTRANET)

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

 
Student Name:
Blank line  
  1. What are the start and end dates of any semesters, quarters, terms, or sessions that will occur during the length of the student’s school or training period? (A school calendar may also be provided.)
    Blank line  
    Blank line  

SECTION B - DISCRETIONARY FUNDS

Students who are receiving discretionary funds paid by a training provider cannot be approved for the CTB program and may not be eligible to receive UI benefits. Discretionary funds are defined as cash in-hand payments, not including payments for tuition, books, supplies, or transportation. If the student is receiving discretionary funds, he or she must waive the receipt of discretionary funds in order to be eligible for the CTB program. If the student is receiving discretionary funds, please answer questions 1 and 2 below:
  1. What is the amount and purpose of the discretionary funds?
    Blank line  
  2. Has the student waived receipt of the discretionary funds?

SECTION C - AUTHORIZING PROGRAM INFORMATION

If the school or training program for this student is authorized, funded, managed, or sponsored by one of the following programs or sources, check the appropriate box below and provide the authorized program information for verification purposes.
Is the student an active journey or master-level union/association member?
Authorized Representative’s Name:
Blank line  
Phone
Blank line 
Name of Organization:
Blank line  
Phone
Blank line 
Address:
Blank line 
City
Blank line 
State
Blank line 
ZIP
Blank line 
By signing below you agree to the following statement:
I certify the information I provided on this form concerning the training enrollment of the student named above is true and correct.
Representative’s Signature:
Blank line  
Date Signed
MM/DD/YYYY
Representative’s Name:
Blank line  
Representative’s Title:
Blank line  
Phone
Blank line 
EDD Contact Information
If you have any questions about this questionnaire, the CTB program, or if you need to make any corrections to the information you have supplied, you can contact the EDD CTB Unit by fax at ‎1-855-873-4359, by mail at Employment Development Department, P.O. Box 599000, Elk Grove, CA 95759, by going online to the EDD website at www.edd.ca.gov and selecting the “Contact EDD” tab, or by calling the toll-free number at ‎ 1-800-300-5616.
 

Form Tracking:

DE 4365TP Rev. 5 (10-15) (INTRANET)