AUTHORIZATION, AGREEMENT AND CERTIFICATION OF TRAINING 1. Applicant's Name (Last, First, Middle Initial) A. Agency, code agency subelement and submitting office number B. Request Status (Mark (X) one) Resubmission Correction Initial Cancellation Section A - TRAINEE INFORMATION Please read instructions on page 6 before completing this form 2.Social Security Number/Federal Employee Number 3. Date of Birth (yyyy-mm-dd) 4. Home Address (Number, Street, City, State, ZIP Code) (Optional) 5. Home Telephone (Optional) (Include Area Code) 6. Position Level (Mark (X) one) a. Non-supervisory c. Supervisory b. Manager d. Executive 7. Organization Mailing Address (Branch-Division/Office/Bureau/Agency)) 8. OfficeTelephone (Include Area Code and Extension) 9. Work Email Address 10. Position Title 11. Does applicant need special accomodation? Yes No If yes, please describe below 12. Type of Appointment 13. Education Level (click link to view codes or go to page 7) 14. Pay Plan 15. Series 16. Grade 17. Step Section B - TRAINING COURSE DATA 1a. Name and Mailing Address of Training Vendor (No., Street, City, State, ZIP Code) 1b. Location of Training Site (if same, mark box) 1c. Vendor Telephone Number 1d. Vendor Email Address 2a. Course Title 2b. Course Number Code 3. Training Start Date (Enter Date as yyyy-mm-dd) 4. Training End Date (Enter Date as yyyy-mm-dd) 5. Training Duty Hours 6. Training Non-Duty Hours 7. Training Purpose Type (Click link to view codes or go to page 9) 8. Training Type Code (Click link to view codes or go to page 9) 9. Training Sub Type Code (Click link to view codes or go to page 9) 10. Training Delivery Type Code (Click link to view codes or go to page 12) 11. Training Designation Type Code (Click link to view codes or go to page 13) 12. Training Credit 13. Training Credit Type Code (Click link to view codes or go to page 13) 14. Training Accreditation Indicator (Check below) Yes 18. Training Objective No 15. Continued Service Agreement Required Indicator (Check below) Yes No N/A 16. Continued Service Agreement Expiration Date (Enter date as yyyy-mm-dd) 17. Training Source Type Code (Click link to view codes or go to page 13) 19. AGENCY USE ONLY Section C - COSTS AND BILLING INFORMATION 1. Direct Costs and Appropriation / Fund Chargeable 2. Indirect Costs and Appropriation / Fund Chargeable Item a. Tuition and Fees b. Books & Material Costs c. TOTAL Amount Appropriation Fund a. Travel Item Amount Appropriation Fund $ $ $ $ $ $ b. Per Diem c. TOTAL 3. Total Training Non-Government Contribution Cost 6. BILLING INSTRUCTIONS (Furnish invoice to): 4. Document / Purchasing Order / Requisition Number 5. 8 - Digit Station Symbol (Example - 12-34-5678) U.S. Office of Personnel Management Page 1 NSN 7540-01-008-3901 American LegalNet, Inc. www.FormsWorkFlow.com Standard Form 182 Revised December 2006 All previous editions not usable. Section D - APPROVALS 1a. Immediate Supervisor - Name and title 1b. Area Code / Telephone Number 1c. Email Address 1d. Signature 1e. Date 2a. Second-line Supervisor - Name and title 2b. Area Code / Telephone Number 2c. Email Address 2d. Signature 2e. Date 3a Training Officer - Name and title 3b. Area Code / Telephone Number 3c. Email Address 3d. Signature 3e. Date Section E - APPROVALS / CONCURRENCE 1a. Authorizing Official - Name and title 1b. Area Code / Telephone Number 1c. Email Address 1d. Signature Approved Disapproved 1e. Date Section F - CERTIFICATION OF TRAINING COMPLETION AND EVALUATION 1a. Authorizing Official - Name and title 1b. Area Code / Telephone Number 1c. Email Address 1d. Signature 1e. Date TRAINING FACILITY ~ Bills should be sent to office indicated in item C6. l Please refer to number given in item C4 to assure prompt payment. U.S. Office of Personnel Management Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Standard Form 182 Revised December 2006 All previous editions not usable. Privacy Act Statement Authority This information is being collected under the authority of 5 U.S.C. § 4115, a provision of The Government Employees Training Act. Purposes and Uses The primary purpose of the information collected is for use in the administration of the Federal Training Program (FTP) to document the nomination of trainees and completion of training. Information collected may also be provided to other agencies and to Congress upon request. This information becomes a part of the permanent employment record of participants in training programs, and should be included in the Governmentwide electronic system, (the Enterprise Human Resource Integration system (EHRI) and is subject to all of the published routine uses of that system of records. Effects and Nondisclosure Providing the personal information requested is voluntary; however, failure to provide this information may result in ineligibility for participation in training programs or errors in the processing of training you have applied for or completed. Information Regarding Disclosure of your Social Security Number (SSN) Under Public Law 93-579, Section 7(b) Solicitation of SSNs by the Office of Personnel Management (OPM) is authorized under provisions of the Executive Order 9397, dated November 22, 1943. Your SSN will be used primarily to give you recognition for completing the training and to accumulate Governmentwide training statistical data and information. SSNs also will be used for the selection of persons to be included in statistical studies of training management matters. The use of SSNs is necessary because of the large number of current Federal employees who have identical names and/or birth dates and whose identities can only be distinguished by their SSNs. U.S. Office of Personnel Management Page 3 American LegalNet, Inc. www.FormsWorkFlow.com Standard Form 182 Revised December 2006 All previous editions not usable. Note: This agreement must be signed by the nominee for Government training that exceeds 80 hours (or such other designated period, less than 80 hours as prescribed by the agency) for which the Government approves payment of training costs prior to the commencement of such training. Nothing contained in this SAMPLE agreement 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. Continued Service Agreement Employees, who are selected to training for more than a minimum period as prescribed in Title 5 USC 4108