ETA 6-131C Right to Appeal

OMB Control Number 1205-0219
Expires: 05/31/2016
Public Burden Statement
Reason for Appeal (Check one)
U.S. DEPARTMENT OF LABOR Employment and Training Administration
Office of Job Corps

RIGHT TO APPEAL

Decision to discharge
(Center Director)
Recommendation for disciplinary
discharge (Fact-Finding Board)

I have been informed of my right to have a reasonable amount of time in which to submit an appeal. If I decide to appeal I may be
given the assistance of any individuals on center to prepare the written and signed statement.
Student Name

Student ID Number

Date

(Month, Day, Year)

Check One
I elect:

not to appeal

to appeal for the following reasons: (If additional space is needed, use reverse)

OMB Control Number 1205-0219
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control
number and expiration date. Public reporting burden for this collection of information, which is required to obtain or
retain benefits (29 USC 2881), is estimated to average 60 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and the completing and
reviewing the collection of information. This information collection is for program management and Congressional
reporting purposes. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Job Corps. Room N-4507,
Washington, D.C. 20210 (Paperwork Reduction Project 1205-0219).

Student’s Signature and Date

(Formerly JC Forms 144C and 144D)

Date Appeal Received by Center
Director

U.S. Government Printing Office: 1977-720.665.6677 3.1

ETA 6-131C (Apr. 1977)