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L7 <br />EEN 11,14 M <br />Program Title; aQr p,.� af„yr l t�� 'grogram Length: _ t Vi _; Date: L1c:I <br />Location of Program: Center ❑ District ❑ Region ❑ Corporate CE Offerin - Jo ❑ Yes - Number of Units: CE Activity Number: <br />m <br />Center Nae: `VIAi n ,1 Center Numher: � <br />�—� �3Course Materia! Attached: s ❑ No <br />Train erfFacilitator Name (Print): t ° Signature: <br />Sfanaturn of Trainor nr Farratzinr P—fm- 11,4 er,., iJ .,........ <br />Employee Name Please Print <br />rinvidum <br />Title Signature <br />LIFE rrerarrrry. <br />Last 4 SS# <br />Type of Tralnin Check one <br />RB <br />CORE <br />Non -CCA <br />�–VAI, <br />At <br />Olt <br />-v <br />CU <br />iL e C r <br />s _ 7 -r - <br />Y' n <br />LVA/ <br />1 C...- <br />iv <br />uiy-9naiure aoove inorsates i anenaea the train Ing program ids niified on thrs corm, <br />RB Rale Based <br />CORE Care <br />Non -CCA Non-Cojpwte Com lianoe Agreemerit CCA <br />FIRM 22001-02 (0111MB) R <br />Page 1 of <br />01 <br />0 <br />