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Contractor Name <br />Address <br />EEO Officer <br />Trainee Name <br />Address <br />City <br />City <br />❑ Hispanic <br />❑ Black <br />Gender <br />❑Female ❑Male <br />Start Date Termination Date <br />Minnesota Department of Transportation EEO Special Provisions <br />Office of Civil Rights <br />On -the -Job Training Program <br />Trainee Termination Form <br />County Prime Sub <br />State Zip <br />Phone # e-mail address <br />Phone # Social Security No. <br />State Zip <br />Race/Ethnicity <br />❑ White ❑ Asian <br />❑ American Indian ❑ Other <br />Classification/Trade S.P. # <br />Hours Assigned <br />Reason for Termination/Separation/Layoff: <br />n Construction phase completed <br />(Death <br />(Fired (please explain below) <br />IIllness/health problems <br />(Lack of transportation and /or travel distance <br />IMilitary duty <br />(Relocated <br />(Personal <br />(Quit to work for another company <br />n Other (please explain below) <br />Please provide comments: <br />Contractor's Representative Signature <br />Hrs Completed <br />Title Date <br />MAIL or Fax THE ORIGINAL and MAINTAIN COPY: <br />395 John Ireland Boulevard <br />St. Paul, MN 55155-1899 <br />Office of Civil Rights M.S. 170 <br />On -The —Job Training Coordinator <br />Fax # 651/366-3129 <br />07/12 <br />EEO Page 26 <br />