ON-THE-JOB TRAINING INVOICE

This is to certify that the above named OJT Trainee has completed and been paid for straight-time work/training(excluding vacations, holidays, sick leave, personal leave, union dues, jury duty, commissions, bonuses or special compensation for work in excess of the maximum hours per week authorized by law) as indicated by the attached copy of the paystubs or payroll record.

OJT Trainee Name

AddressAddress

City, State, ZipCity, State, Zip

Phone/Fax NumberPhone/Fax Number

Service Provider Name Employer (Company) Name

Request for payment at:

This invoice is to request a training reimbursement amount of for the period of to

# of Hours Worked to Date Hourly Wage Reimbursement %

The following mandatory documents have been verified and attached:

OJT Trainee completed On-The-Job Training

For invoice at completion only:

OJT Trainee Name Signature Date

ExhibitAttachment - On-The-Job Training Policy and Procedures

Chapter 4. Part 1: Adult and Dislocated Worker Program Activities

OJT Agreement #- -

1. Payroll Records; and

2. Clarification of Hours.

Authorized Employer Representative Name Signature Date

I hereby certify that I have worked the hours indicated above and that the attached documents are true and correct.

*Discontinuance: OJT Trainee did not completeDiscontinuation Date:

*The AJCC BSR must update the activity code and include the reason for the discontinuance in a case note.

Revised July 2020 1 of 1

End of Fiscal Year

Employer Match AmountEmployer ReimbursementWIOA ER NDWG

ER NDWG