1. Company Name

2. Contact Name

3. Phone Number

4. Please select the Ohio targeted industry identified by your company's NAICS code.

Please answer the following questions about the employees you want to train.

5. Are the employees located within Ohio?

6. Please indicate the employees' business function. Check all that apply.

7. Do all of these employees earn at least $10.88/hr. plus benefits? (150% of Ohio Minimum wage as of Jan. 1, 2012)

8. Are these employees Ohio residents?

9. Are these employees at least 18 years old?

10. Do the employees work at least 25 hours per week?