ࡱ> DB=>E` bjbj 7l,WHHH(܊n,HDDDDDVV`9;;;;;;$h_-DD--_DD(-DD9-9hD сmH|%D >0n5|=  DZ@P4__IXn----BI?I( REQUEST, AUTHORIZATION, AGREEMENT AND CERTIFICATION OF TRAININGA. Agency, code agency subelement and submitting office number (Example-xx-xx-xxxx)01B. OFFICE USE ONLY -TIGTA-4082C. Request status (Mark (X) one)02 FORMCHECKBOX Initial or Resubmission FORMCHECKBOX Correction or Cancellation %Section A  TRAINEE INFORMATION%1. Applicant s name(Last-First-Middle Initial) Doe John MEnter first 5 letters of last name032. Social Security Number043. Date of birth (Year and Month)05(Example-born January 14, 1943 Shown as 43/01)Doexxxx-xx-1234 4. Home address (Number, street, city, state, Zip code)5. Home telephone6. Position level (Mark (X) one only) FORMTEXT        FORMTEXT      Area Code  FORMTEXT      Number  FORMTEXT       FORMCHECKBOX a. Non-supervisory FORMCHECKBOX c. Manager FORMCHECKBOX b. Supervisory FORMCHECKBOX d. Executive7. Organization mailing address (Branch-Division/Office/Bureau/Agency) Human Resources Office of Management Services/TIGTA IG:MS:HR:HC8. Office Telephone9. Continuous civilian service10. Number of prior non-government training days Area Code 202Number 622-1234YearsMonths 11a. Position title/function Program Analyst/Human Capital11b. Applicant handi-capped or disabled (See instructions) FORMCHECKBOX 12. Pay plan/series/grade/step GS/343/12/0113. Type of appointment  FORMTEXT      14. Education level  FORMTEXT      %Section B  TRAINING COURSE DATA%15a. Name, mailing address and website of training vendor (No., street, city, state, Zip code)15b. Location of training site (if same, mark box) FORMCHECKBOX American Training Association 222 Second Street Washington, D.C. 20000  HYPERLINK "http://www.americantraining.com" www.americantraining.com  FORMTEXT        FORMTEXT        FORMTEXT      16. Course title and training objectives (Benefits to be derived by the government) Federal IT Investment and Project Management; Provides employee with Project Management Skills; Covers Needs Statements, Feasibility Study, Project Plan, Cost/Benefit Analysis, Risk Analysis Method of Payment  FORMCHECKBOX  Normal Billing  FORMCHECKBOX  Small Purchase Card 17. Catalog/Course No.18. Training period (6 digits)0619. No. of course hours (4 digits)0720. Training codes (See instructions)YearMonthDaya. During duty40a. PurposeCode08 c. SourceCode10a. Start051001b. Non-dutyb. Complete051005c. TOTAL40b. Type09 d. Special interest11AGENCY USE ONLY Attach a Privacy Act Statement, Justification, and brochures for all courses.%Section C-ESTIMATED COSTS AND BILLING INFORMATION%%Section D-APPROVALS%21. Direct costs and appropriation/fund chargeable26a. Immediate Supervisor-Name , title and signature Jane Doe Manager,Human CapitalArea code/Tel No./Extension 202-222-3333ItemAmountAppropriation/fundDollarsCentsa. Tuition500002001-xxxx-xxxx-xxxx-xxxx-xx-xxxxb. Books or materialsDate c. Other (Specify) 27a. Second Line supervisor-Name, title and signature John Smith, Director, Human ResourcesArea code/Tel No./Extension 202-222-4444d. (Enter 4 digits in dollar column) TOTAL %1250000 Date 22. Indirect costs and appropriation/fund chargeable%Section E- CONCURRENCE%ItemAmountAppropriation/fund28a. Training officer-Name, title and signature Jane Smith Training CoordinatorArea code/Tel No./Extension 202-222-5555a. TravelDollarsCents Purpose Code Tb. Per diemDate c. Other (Specify) 29a. Authorizing official-Name, title and signature John Jones Plan ManagerArea code/Tel No./Extension 202-222-6666d. (Enter 4 digits in dollar column) TOTAL %13Date 23. Obligation Number/Document/Purchase Order/Requisition No.  24. 8-Digit station symbol (e.g. 12-34-567)20-04-0001%Section F-CERTIFICATION OF TRAINING COMPLETION%25. BILLING INSTRUCTIONS (Furnish invoice to): Accounting Services Branch UNB Building  8th Floor Bureau of the Public Debt P.O. Box 1328 Parkersburg, WV 26101-132825b. Pre-payment  FORMCHECKBOX  Yes  FORMCHECKBOX  Nob. Signature Date TRAINING FACILITY % Bills should be sent to office indicated in item 25 Please refer to number given in item 23 to assure prompt payment.Copy 1 AGENCY (TRAINING /PERSONNEL FOLDER) 182-106 Standard Form 182 (Modified RI-WR 11/98) NSN-7540-01-008-3901 Previous edition usable U.S. Office of Personnel Management FPM Chapter 410  NOTE: This agreement must be signed by the nominee for all non-government training that exceeds 80 hours (or such other designated period, 80 hours or less, as prescribed by the agency) and for which the Government approves payment of training costs prior to the commencement of such training. Nothing contained in Section G below shall be construed as limiting the authority of an agency to waive, in whole or in part, an obligation of an employee to pay expenses incurred by the Government in connection with the training.  Section GEMPLOYEES AGREEMENT TO CONTINUE IN SERVICE I AGREE that, upon completion of the Government-sponsored training described in this request, if I receive salary covering the training period, I will serve in the agency three times the length of the training period. If I receive no salary during the training period, I agree to serve the agency for a period equal to the length of training, but in no case less than one month. (The length of part-time training is the number of hours spent in class or with the instructor. The length of full-time training is eight hours for each day of training, up to a maximum of 40 hours a week). NOTE: For the purposes of this agreement, the term agency refers to the employing organization (such as an Executive Department or independent establishment), not to a segment of such an organization. If I voluntarily leave the agency before completing the period of service agreed to in item 1 above, I AGREE to reimburse the agency for the tuition and related fees, travel and other special expenses (EXCLUDING SALARY) paid in connection with my training. These amounts are reflected in items 21 and 22. I FURTHER AGREE that, if I voluntarily leave the agency to enter the service of another Federal agency or other organization in any branch of the Government before completing the period of service agreed to in item 1 above, I will give my organization written notice of at least ten working days, during which time a determination concerning reimbursement will be made. If I fail to give this advance notice, I AGREE to pay the amount of additional expenses (5 U.S.C. 4109(a)(2)) incurred by the Government in this training. I understand that any amounts which may be due the agency as a result of any failure on my part to meet the terms of this agreement may be withheld from any monies owed me by the Government, or may be recovered by such other methods as are approved by law. I FURTHER AGREE to obtain approval from my organization training officer and that person responsible for authorizing non-government training requests of any proposed change in my approved training program involving course and schedule changes, withdrawals or incompletions, and increased costs. I acknowledge that this agreement does not in any way commit the Government to continue my employment. I understand that, if there is a transfer of my service obligation to another Federal agency or other organization in any branch of the Government, the agreements in items 1, 2, and 3 of this section will remain in effect until I have completed my obligated service with that other agency or organization.31. Period of obligated service (For non-government training only) ( 32. Employees signatureDatePRIVACY ACT STATEMENTGeneral-This information is provided pursuant to Public Law 93.579 (Privacy Act of 1974), December 31, 1974, for individuals completing Federal nomination for training forms. Authority-The Government Employees Training Act of 1958 (U.S. Code, Title 5, sections 4101 to 4118). Purposes and Uses-The information on this form is used in the administration of the Federal Training Program. The purpose of this form is to document the nomination of trainees and completion of training; and it serves as the principal repository of personal, fiscal and administrative information about trainees and the programs in which they participate. The form becomes a part of the permanent employment record of participants in training programs and is included in the Governments Central Personnel Data File. 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