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U.S. Department of Labor  			                                                 OMB Control No. 1205-0439
Employment and Training Administration                                                      Expiration Date:  XX/XX/XXXX

Project Synopsis Form ETA 9106
 National Dislocated Worker Grants Electronic Application System 

State of _______
Amount of Funding Request  $____________
Amount Approved by DOL $_____________                     
Project Name:  
Project Type:       ___Employment Recovery       ___Disaster Recovery     ___Trade Dual Enrollment       

Application Type:   ___Full   ___Emergency 
(If Emergency – reason :  __________________________________________________________________________________)  
For Employment Recovery Project Application ONLY:

Description/Type of Eligible Dislocation Event :  ___Plant Closure/Mass Layoff    ___Community Impact Layoffs 
  ___Military Installation                ___Industry Wide       ___Dislocated Service Members

Description of Activities to be Provided:


For Disaster Recovery Project Application ONLY:

Name/Description of  Disaster Event/Activities to be Provided:________________________________________________________________________

Date of FEMA Declaration of Eligibility for Public Assistance: __________; or

Date of Emergency or Disaster Situation of National Significance: ________

Name of Federal Agency Declaring Disaster Event (if other than FEMA): __________ 

Target Groups (check all that apply):  ___Unemployed Due to Disaster  ___Long-Term Unemployed  ___Dislocated Workers  ____Evacuees From a Declared Disaster Area



 
Applicant Contact Person:
Street Address 1:
Street Address 2:
City: ____________________________    State: _________________________  Zip Code 
Telephone:
FAX:
Email:
Planned Number of Participants: __________
Planned Entered Employment Rate: __________%
Planned Cost Per Participant:  $___________
Actual Cost Per Participant in Prior PY: $ __________
% of Planned Participants Receiving NRPs: _______
Planned Earnings: ___________%
Counties Included in Project Service Area: 
Project Operator Listing: 


  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 60 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).