IUOE Local 286
  • MAP Fund Information
  • Pre-Authorization Form
    Updated On: Oct 24, 2011

    TRAINING TRUST PRE-AUTHORIZATION FORM (41)

    TRAINING TRUST PRE-AUTHORIZATION FORM (41)

    Participant to complete parts A & B

     

    PART A

     

    Name _______________________________________________________ Date ___________________

     

    Address _____________________________________________________________________________

     

    City _________________________________________________ State __________ Zip ____________

     

    Telephone (home) _________________________________ (work) ______________________________

     

    Employer ______________________________ Site ______________ Work Shift & Hours __________

     

    Have you taken this class before?          yes                 no

     

    Eligible Participant                                  yes                no

     

        Stationary Engineer     Custodial Engineer  Other Skilled Occupation  ________________

     

    ***********************************************************************************

    PART B

     

    Training Institution __________________________________________________________________

     

       Public School    Private    School Seminar    Specialty Training

     

    Class Title _________________________________________________________________________

     

    Estimated Cost of Tuition or Class Fee @ 100% $ _____________________

     

    Estimated Cost of Materials @ 75%                   $ _____________________

     

    Estimated Travel Cost (if applicable)                  $ _____________________

     

    Class Starting Date ________________________ Time Starts ____________ Ends _________

     

    Class Ending Date ________________________________ Total Class Hours _____________

     

    Circle Class Day(s):  Monday   Tuesday   Wednesday   Thursday   Friday   Saturday

     

    By signing this form the applicant acknowledges a pre-determination procedure is set in motion for a benefit provision and further acknowledges receipt of the appeals procedure located on the back of this form.

     

    Name _______________________________________  Date ______________________

     

    Send Completed form to: Fax 253-351-0639 or

    Mail to:             Western Washington Stationary Engineers Training Trust

                            Joint Apprenticeship & Training Committees

                            18 E Street SW

                            Auburn, WA 98001-5256

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