General Information: The Organization |
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I. Please provide your organizational information EXACTLY as it should appear on the AZ "Mature Worker Friendly" Employer Certification documents. |
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| Organization Name | |
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| (HQ) Address | |
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| Local Address (if different than HQ) | |
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| Local City | |
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| Zip Code | |
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| Telephone Number | |
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| Fax Number | |
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| Complete Web Address | |
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II. Please provide your CEO's (or top executive's) name and title EXACTLY as it should appear on the AZ "Mature Worker Friendly" Employer Certification documents (please give information for AZ location only) |
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| Name | |
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| Title | |
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| Telephone Number | |
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| E-mail Address * (required) | |
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| Work Address (if different from above) | |
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| City, State, Zip | |
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General Organization Demographics: This section (Question V) requires information for Arizona locations only |
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| III. Which of the following best describes your organization? (ONE Answer) | |
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IV. What is the total number of locations your organization has in the U.S.? (The number should include U.S. territories in the Caribbean and Pacific). What is the total number of locations your organization has in Arizona? |
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NOTE: The "Mature Worker Friendly" Employer Certification is available for your Arizona location(s) only. |
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| a. # of Locations in U.S. | |
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| b. # of Locations in Arizona | |
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If you have multiple locations, a small amount of additional information about how you plan to share the Certification Training throughout your locations will be needed. You will be contacted with details on this aspect of your application. |
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V. Please provide the employee numbers (as requested below) for your Arizona location(s) only, AND describe the general make up of your organization. |
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| a. How many total full-time employees do you have? | |
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| b. How many total part-time employees do you have? | |
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| c. How many age 50+ employees do you have? | |
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| 50+ Full-time | |
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| 50+ Part-time | |
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| d. How many years has your company been in business? | |
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| VI. Which category best describes your organization's business? (Check one) | |
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| Please share with us how you learned about the Mature Worker Friendly Employer Certification? (i.e. - fellow employer, newspaper story, Jobing.com, etc.) * (required) | |
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General Information: Primary Staff Contact |
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Name of primary contact person at your company for questions or details related to this application: |
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| Name | |
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| Title | |
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| Work Telephone Number | |
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| Fax Number | |
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| Work E-Mail Address | |
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| Work Address (if different from #1 above), Street | |
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| City, State, Zip | |
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Training Designee |
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Please indicate the name(s) of the primary individual(s) that will attend the required 2 1/2 hour training on behalf of your organization: |
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| Why Designated? | |
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| Name | |
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| Why Designated? | |
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| Name | |
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| Why Designated? | |
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Application Deadline |
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Certification applications are accepted one time each year. For 2010, applications will be accepted beginning May 17, 2010. Closing date for 2010 applications to be determined. |
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Next Steps |
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After your fully completed application has been received prior to the application deadline, and then processed, you will be contacted in late July regarding the training date options for your organization. |
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Upon completion of the required 2 1/2 hour training, the receipt of any additional information that may be requested, and your payment of $25 (to cover employer materials), your organization will receive its Certification. |
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