ETA-9106 Project Synopsis Form

Project Synopsis Form

OMB Approval No. 1205-0439

Expiration date: 01/31/07

State of ___	Amount of Funding Request $____________		Amount Approved by DOL $__________
Project Name:
Project Type: __Regular __Disaster __ Trade Dual Enrollment __ Trade Health Insurance Coverage
Application Type: __Full __ Emergency (If Emergency, reason:___________________________________________________________________)
For Regular Project ONLY, type of Eligible Dislocation Event: __Plant Closure/Mass Layoff __Community Impact Layoffs __ Military Installation __ Industry wide  NAIC Code
For Disaster Project Application ONLY: Name/Description of Disaster Event: ________________________________________________ Date of FEMA Declaration of Eligibility for Public Assistance: __________ Target Groups (check all that apply): __Unemployed due to Disaster __Long-Term Unemployed __Dislocated Workers
For Trade Health Insurance Coverage Project Application ONLY: State-based Qualified Health Insurance Coverage Programs Selected by State __Continuation Provision __High-Risk Pool __State Employees __State Employee-Comparable __Joint State-Private Non-pool __Joint State-Private Pool __Non-federally Financed
Applicant Contact Person:
Street Address 1:
Street Address 2:
City: _____________________________ State: _______ Zip Code: _________
Telephone:
FAX:
Email:
Planned Number of Participants: __________		Planned Entered Employment Rate: _____%
Planned Cost per Participant: $___________		Actual Cost per Participant in Prior PY: $__________
% of Planned Participants Receiving NRPs: _____%		Planned Wage Replacement Rate: _____%
Counties included in Project Service Area:
Project Operator Listing:

ETA 9106 (January 2003)