On behalf of the Program Sponsor, I request the Administrator of Apprenticeship cancel the agreement of the above
referenced apprentice effective __________________________________.
7. Other: _______________________________________________________________________________________
and a copy of supporting documents/records will be held for 35 days for the Administrator; I further certify that the apprentice
has been notified of the right to "appeal to the Administrator of Apprenticeship". (Orginals must be retained for 5 years)
Signature ________________________________________________ Date _______________________________________
Printed Name _____________________________________________
DAS Form 5 (Rev. 9/06)
Falsification of records.
Failure to attend and/or perform satisfactorily in classes of related and supplemental instruction.
Improper conduct on the job or in the classroom, such as fighting, being under the influence of drugs or alcohol,
stealing, abusive language, etc.
Violation of Apprentice Agreement.
Failure to comply with the Rules and Regulations of the Program Sponsor.
Failure to complete work requirements.
Request for Cancellation of Apprentice Agreement
Name of DAS Consultant:
P. O. Box 420603
State of California
Adminstrator of Apprenticeship
Division of Apprenticeship Standards
Department of Industrial Relations
San Francisco, CA 94142-0603
Program Sponsor Name
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:
Name of Apprentice
Social Security No.