Program Registration and Apprenticeship Agreement

Part A: To Be Completed By Apprentice Note to Sponsor: Part A Should Only Be Filled Out By Apprentice.

1. Last Name
First Name
Middle Name
Street Address
Zip Code
Telephone Number:
Social Security Number:
2. Date Of Birth
3. Sex (Mark One)

Answer Both A and B (Voluntary)
(Definitions on Reverse)

4a. Ethnic Group (Mark One)
4b. Race (Mark One or more)
5. Veteran Status (Mark One)
6. Education Level (Mark One)
7a. Employment Status (Mark one)
7b. Career Linkage or Direct Entry (Mark One) (Instruction on reverse)
8. Signature of Apprentice
9. Signature of Apprentice

Part B: Sponsor: Except for items 6, 7, 8, 10a. - 10c, Remainder of items repopulated from program registration.

1.Sponsor Program No.

Sponsor Name and Address (No. Street, City, Country, State, Zip Code)

Brookins Construction School
Detroit, Michigan 48209

2a Occupation (The Work processes listed in the standards are part of this agreement).


2b Occupation


2b. 1. Interim Credentials only applicable to part B, 3.b. and 3.c. (Mark One)
3. Occupation Training Approach (Mark One)
4. Team

5200-8000 HR

5. Probationary Period

1000 HRS

6. Credit for Previous Experience
7. Term Remaining
8. Date Apprenticeship Begins
9a. Related Instruction (Number of Hours Per Year)


9b. Apprentice Wages for Related Instruction
9c. Related Training Instruction Source

Brookins Construction School
1930 Division Street
Detroit Michigan 48209

10. Wages: (Instructions on reverse)
10a. Pre-Apprenticeship Hourly Wage
10b. Apprentice's Entry Hourly Wage
10c. Journey Worker's Hourly Wage
Check Box
10d. Term
10e. Wage Rate (Mark One)
Period 1 (1000)
Period 2 (1000)
Period 3 (1000)
Period 4 (1000)
Period 5 (1000)
Period 6 (1000)
Period 7 (1000)
Period 8 (1000)
Period 9
Period 10
11. Signature of Sponsor's Representative(s)
Date Signed
12. Signature of Sponsor's Representative(s)
Date Signed
13. Name and Address of Sponsor Designee to Recive Complaints
(If applicable)

Daniel Brookins, Jr.
1930 Division Street
Detroit Michigan 48209

Part C: To Be Completed by Registration Agency

1. Registration Agency and Address
2. Signature (Registration Agency)
3. Date Registered
4. Apprentice Identification Number (Definition on reverse)