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[]
[null,"State of California"]
[null,"Administrator of Apprenticeship"]
[null,"Department of Industrial Relations"]
[null,"Division of Apprenticeship Standards"]
[null,"P. O. Box 420603"]
[null,"San Francisco, CA  94142-0603"]
[]
[null,"Request for Cancellation of Apprentice Agreement "]
[null,"(For Cause)"]
[null,"Program Sponsor Name",{"$nulls":14},"File No."]
[null,"Address"]
[{"$nulls":3},"Street",{"$nulls":8},"City",{"$nulls":5},"Zip"]
[]
[null,"To: ","Name of DAS Consultant:"]
[null,null,"Address:"]
[]
[null,"Reference:",null,"Name of Apprentice"]
[null,null,"Social Security No.",{"$nulls":9},"Indenture Date"]
[null,null,"Address:"]
[{"$nulls":5},"Street",{"$nulls":6},"City",{"$nulls":5},"Zip"]
[]
[]
[null,"     On behalf of the Program Sponsor, I request the Administrator of Apprenticeship cancel the agreement of the above"]
[null,"referenced apprentice effective __________________________________."]
[]
[null,"     I declare under penalty of perjury that I am familiar with the facts upon which this request is based and I believe this action complies with the program standards and rules and regulations and is based on:"]
[]
[null,null,{"v":1,"d":"1."},"Failure to complete work requirements."]
[null,null,{"v":2,"d":"2."},"Failure to attend and/or perform satisfactorily in classes of related and supplemental instruction."]
[null,null,{"v":3,"d":"3."},"Improper conduct on the job or in the classroom, such as fighting, being under the influence of drugs or alcohol, stealing, abusive language, etc. "]
[]
[null,null,{"v":4,"d":"4."},"Violation of Apprentice Agreement."]
[null,null,{"v":5,"d":"5."},"Failure to comply with the Rules and Regulations of the Program Sponsor."]
[null,null,{"v":6,"d":"6."},"Falsification of records."]
[null,null,{"v":7,"d":"7."},"Other:  _______________________________________________________________________________________"]
[]
[]
[null,"and a copy of supporting documents/records will be held for 35 days for the Administrator; I further certify that the apprentice"]
[null,"has been notified of the right to \"appeal to the Administrator of Apprenticeship\". (Original documents must be retained for 5 years)"]
[]
[]
[null,"Signature ________________________________________________   Date _______________________________________"]
[null,"                                         Program Sponsor                                                                                                            "]
[null,"Printed Name _____________________________________________"]
[]
[null,"at ",{"$nulls":7},", California"]
[{"$nulls":4},"City"]
[null,"DAS Form 5 (Rev. 9/06)"]