Assessment Center Registration Form

Please use this form to register your school, agency or business as a Florida Ready to Work Assessment Center. An organization may have multiple Assessment Center locations. Please submit a separate form for each Assessment Center. Upon receipt of the form, the Primary Contact will be contacted by a Florida Ready to Work Project Coordinator to verify registration as a Florida Ready to Work Assessment Center within 2 business days.

Note: * equals Required Fields.

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Assessment Center Information

Physical Location of program delivering FRW assessments, as appears on signage or how the program is best known. This is how the Assessment Center will be listed on the FRW website.

Assessment Center Name:	Assessment Center Name This field indicates the name of the physical location of your school, agency or business that will deliver the Florida Ready to Work program, as it appears on signage or how the program is best known. This is how the Assessment Center will be listed on the Florida Ready to Work website. This is a required field. *
Physical Address:	Assessment Center Physical Address This field indicates the physical location of your school, agency or business that will deliver the Florida Ready to Work program. This is the Street Address that will be listed on the Florida Ready to Work website. This is a required field. *
City:	Assessment Center City This field indicates the City in which your school, agency or business is located. This is a required field. *
State:	Assessment Center State This field indicates the State in which your school, agency or business is located. This is a required field. *
Zip:	Assessment Center Zip This field indicates the Zip Code of the physical location of your school, agency or business that will deliver the Florida Ready to Work program. This is a required field. The value for this field must be in the format ##### or #####-####. *
County:	Assessment Center County This field indicates the County in which your school, agency or business is located. This is a required field. Please select the appropriate County from the drop-down list. Please Choose a County Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia DeSoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin MiamiDade Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns St. Lucie Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington *
Type:	Assessment Center Type This field indicates the population served by your school, agency or business and the streams through which your Assessment Center is funded. This is a required field. Please select the correct Type from the drop-down list. Please Choose a Type Adult Education Charter School Community Based Organization Community College Correctional Institution Employer (Administers Assessment to Employees) FLJJCA High School Juvenile Justice Institution Other Private School Regional Workforce Board Technical Center University *
Population:	Assessment Center Population This field indicates the population served by your school, agency or business to which you will provide the Florida Ready to Work program. This is a required field. Please select the correct Population from the drop-down list. If undecided or unknown at this time, please select the "Undecided" option. Please Choose a Population Undecided at this time Open to Employees Only Open to Public Open to Public - Appointment Required Open to Students and Public Open to Students and Public - Appointment Required Open to Students Only Open to Students Only - Appointment Required *
Telephone:	Assessment Center Telephone This field indicates the telephone number that will be listed on the Florida Ready to Work website for your Assessment Center. This is a required field. The value for this field must be in the format ###-###-####. *
Telephone Extension:	Assessment Center Telephone Extension This field defines the extension of the Assessment Center telephone number. This is an optional field. A valid value for this field is a number between 1 and 99999.
Website:	Assessment Center Website This field indicates the URL of your Assessment Center's Web site. This is a optional field. A valid value for this field is in the form of www.floridareadytowork.com or http://www.floridareadytowork.com/.

Primary Contact

The Primary Contact is the person who is responsible for the implementation of the FRW program and delivery of the FRW Assessments at this Assessment Center.

First Name:	Primary Contact First Name This field indicates the first name of the individual responsible for the implementation of Florida Ready to Work and delivery of the Florida Ready to Work assessments at your Assessment Center. This is a required field. *
Last Name:	Primary Contact Last Name This field indicates the last name of the individual responsible for the implementation of Florida Ready to Work and delivery of the Florida Ready to Work assessments at your Assessment Center. This is a required field. *
Title:	Primary Contact Title This field indicates the Title of the individual responsible for the implementation of Florida Ready to Work and delivery of the Florida Ready to Work assessments at your Assessment Center. This is a required field. *

Mailing Address Checkbox This Checkbox will set the Primary Contact's Mailing Address (including City, State, and Zip) to the Assessment Center's Address. If this Checkbox is checked then the Primary Contact's Address becomes locked and uneditable. Uncheck this Checkbox to directly edit the Primary Contact's Address. Click here if Primary Contact Address is same as Assessment Center Address

Mailing Address:	Primary Contact Mail Address This field indicates the mailing address of the Primary Contact if different from the Assessment Center mailing address. This is a required field. *
City:	Primary Contact City This field indicates the City of the Primary Contact if different from the Assessment Center mailing address. This is a required field. *
State:	Primary Contact State This field indicates the State of the Primary Contact if different from the Assessment Center mailing address. This is a required field. *
Zip:	Primary Contact Zip This field indicates the Zip Code of the Primary Contact if different from the Assessment Center Mailing Address. The value for this field must be in the format ##### or #####-####. This is a required field. *
Telephone:	Primary Contact Telephone This field indicates the telephone number of the Primary Contact if different from the Assessment Center telephone number. The value for this field must be in the format ###-###-####. This is a required field. *
Telephone Extension:	Primary Contact Telephone Extension This field indicates the telephone extension of the Primary Contact. This is an optional field. A valid value for this field is a number between 1 and 99999.
Email:	Primary Contact Email This field indicates the email address of the Primary Contact. This is a required field. The value for this field must be of a valid email format such as jsmith@companyname.com or john.smith@schoolname.edu. *

Alternate Contact (Optional) Alternate Contact Enable Checkbox This Checkbox enables the Alternate Contact fields. When this Checkbox is checked the Alternate Contact fields (including Alternate Contact First Name, Last Name, Telephone, and Email) become Required Fields. The Alternate Contact Title and Telephone Extension are Optional Fields. When this Checkbox is unchecked the Alternate Contact fields are cleared and editing becomes disabled. Click to Enable

First Name:	Alternate Contact First Name This field indicates the first name of the individual to be contacted as an alternate contact for matters dealing with the implementation of Florida Ready to Work and delivery of the Florida Ready to Work assessments at your Assessment Center. This is a required field when above "Click to Enable" Checkbox is checked.
Last Name:	Alternate Contact Last Name This field indicates the last name of the individual to be contacted as an alternate contact for matters dealing with the implementation of Florida Ready to Work and delivery of the Florida Ready to Work assessments at your Assessment Center. This is a required field when above "Click to Enable" Checkbox is checked.
Title:	Alternate Contact Title This field indicates the title of the individual to be contacted as an alternate contact for matters dealing with the implementation of Florida Ready to Work and delivery of the Florida Ready to Work assessments at your Assessment Center. This is an optional field when above "Click to Enable" Checkbox is checked.
Telephone:	Alternate Contact Telephone This field indicates the telephone number of the Alternate Contact if different from the Assessment Center telephone number. The value for this field must be in the format ###-###-####. This is a required field when above "Click to Enable" Checkbox is checked.
Telephone Extension:	Alternate Contact Telephone Extension This field indicates the telephone extension of the Alternate Contact. This is an optional field when above "Click to Enable" Checkbox is checked. A valid value for this field is a number between 1 and 99999.
Email:	Alternate Contact Email This field indicates the email address of the Alternate Contact. This is a required field when above "Click to Enable" Checkbox is checked. The value for this field must be of a valid email format such as jsmith@companyname.com or john.smith@schoolname.edu.

Credential Delivery Information

Delivered To:	Credentials Delivered To This field indicates whether the Credentials earned at your Assessment Center should be delivered to the Credential Contact at the Assessment Center or to the Participant's homes address. Please Choose Assessment Center Student/Jobseeker Address *

Credential Contact

The Credential Contact is the person to whom the FRW Credentials will be mailed if Credentials are NOT mailed to the student/jobseeker address.

** If mail to student/jobseeker address is chosen, a Credential Contact is still required in the case of an undeliverable student/jobseeker address or other Credential matter.

First Name:	Credential Contact First Name This field indicates the first name of the individual responsible for receiving the Credentials earned at your Assessment Center. If mail to student/jobseeker address is chosen, this individual will be contacted in case of a Credential issue or question. This is a required field. *
Last Name:	Credential Contact Last Name This field indicates the last name of the individual responsible for receiving the Credentials earned at your Assessment Center. If mail to student/jobseeker address is chosen, this individual will be contacted in case of a Credential issue or question. This is a required field. *
Title:	Credential Contact Title This field indicates the Title of the individual responsible for receiving the Credentials earned at your Assessment Center. If mail to student/jobseeker address is chosen, this individual will be contacted in case of a Credential issue or question. This is a required field.
Additional Routing Info:	Credential Contact Additional Routing Information This field indicates any additonal routing information to be included with the Credential delivery address. This is an optional field.

Mailing Address Checkbox This Checkbox will set the Credential Contact's Mailing Address (including City, State, and Zip) to the Assessment Center's Address. If this Checkbox is checked then the Credential Contact's Address becomes locked and uneditable. Uncheck this Checkbox to directly edit the Credential Contact's Address. Click here if Credential Delivery Address is same as Assessment Center Address

Mailing Address Checkbox This Checkbox will set the Credential Contact's Mailing Address (including City, State, and Zip) to the Primary Contact's Address. If this Checkbox is checked then the Credential Contact's Address becomes locked and uneditable. Uncheck this Checkbox to directly edit the Credential Contact's Address. Click here if Credential Contact Address is same as Primary Contact Address

Mailing Address:	Credential Contact Mailing Address This field indicates the mailing address of the Credential Contact if different from the Assessment Center mailing address. This is a required field. *
City:	Credential Contact City This field indicates the City of the Credential Contact if different from the Assessment Center mailing address. This is a required field. *
State:	Credential Contact State This field indicates the State of the Credential Contact if different from the Assessment Center mailing address. This is a required field. *
Zip:	Credential Contact Zip This field indicates the Zip Code of the Credential Contact if different from the Assessment Center Mailing Address. The value for this field must be in the format ##### or #####-####. This is a required field. *
Telephone:	Credential Contact Telephone This field indicates the telephone number of the Credential Contact if different from the Assessment Center telephone number. The value for this field must be in the format ###-###-####. This is a required field. *
Telephone Extension:	Credential Contact Telephone Extension This field indicates the telephone extension of the Credential Contact. This is an optional field. A valid value for this field is a number between 1 and 99999.
Email:	Credential Contact Email This field indicates the email address of the Credential Contact. This is a required field. The value for this field must be of a valid email format such as jsmith@companyname.com or john.smith@schoolname.edu. *

Notes

Please supply additional information here or include any questions you may have.

Notes:	Notes This field indicates any additional notes about your potential Assessment Center setup.

		Note: * equals Required Fields.