ETA 9107 Project Operator Data Form

U.S. Department of Labor OMB Control No. 1205-0439

Employment and Training Administration Expiration Date: 9/30/2016

Project Operator Data Form ETA 9107

National Dislocated Worker Grant Electronic Application System

Project Operator:
Street Address 1:
Street Address 2:
City:		State:	Zip Code:
Contact Person:
Telephone:
FAX:
Email:
Duration of Project Operator Agreement:	Start:		End:
	Temporary Jobs		Workforce Development	Total
Funding Level	$		$	$
Number of Participants:
Counties Included in Project Operator Service Area:

Public Burden Statement:

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control number. Respondents’ obligation to complete this form is required to obtain or retain benefits ( PL: 113- 128 sec 170). Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This is public information and there is no expectation of confidentiality. Send comments regarding this burden estimate to the U.S. Department of Labor, Office of National Response, Room C-5311, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0439).