NEW Contractor Safety Training Registration Form by 185Mjt

VIEWS: 4 PAGES: 1

									                                   POLK STATE COLLEGE
                     NON-CREDIT REGISTRATION FOR CONTRACTOR SAFETY
Social Security Number              Last Name                                 First Name                   Middle Initial

     /      /
Permanent Mailing Address                                              City                        State               ZIP Code


Sex                           Date of Birth                  Telephone Numbers

 Male  Female                    /       /                 Home: (           )              Work: (        )
Citizenship

 U.S   IF NON-US, INDICATE STATUS:  Resident Alien  Permanent Resident Alien  Refugee  VISA Student
                                           (Must list your Country of Origin:___________________________________)
Race (Required by the U.S. Office of Education title VI Civil Rights Act of 1964)

 White (Non-Hispanic)  Asian or Pacific Islander  American Indian or Alaska Native  Black (Non -Hispanic  Hispanic

               Course
                          Section
Prefix    Number          Number                      Course Title                   Days   Time        Location            Fee




Parent/Guardian Signature (Required for Dependent Application)_____________________________________Date:_____________

“I DECLARE UNDER PENALTY OF PERJURY PUNISHABLE BY LAW AS A MISDEMEANOR UNDER SECTION 837.06
F.S. THAT THE FOREGOING IS TRUE AND CORRECT.”

Signature:_________________________________________________________________Date:________________

                                       Due to Government restrictions on class size for students renewing their MSHA 5000-
FAX TO:
                                       23 forms (for mining facilities) it is imperative that we know which credentials you are
Barry Fitzgerald                       renewing (check appropriate):
863 669-2324

                                       ____    Florida Phosphate Producers I.D. card (chemical plants only)


                                       ____    MSHA 5000-23 form (mine workers only)


                                       ____ Both (chemical plant card and MSHA 5000-23)




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