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REPLACEMENT CARD / CERTIFICATE REQUEST FORM
THIS FORM IS DESIGNATED FOR INDIVIDUALS WHO HAVE COMPLETED THEIR OSHA TRAINING THROUGH THE NATIONAL SAFETY EDUCATION CENTER
(NSEC). PER OSHA, ONLY AUTHORIZED TRAINERS ARE ALLOWED TO REQUEST REPLACEMENT OSHA 10- & 30-HOUR CARDS. IF YOU ARE NOT A TRAINER, YOU NEED TO
CONTACT THE PERSON WHO CONDUCTED YOUR TRAINING. NO REFUNDS WILL BE ISSUED FOR FAILING TO COMPLY.
Trainer Name: Trainer Expiration Date
(Please print) NSEC ID# on Trainer Card:
Home Address
Work Address
Zip Home
City: State:
Code: Phone:
Cell
Day Phone: Fax: E-Mail:
Phone:
CHECK EACH CARD / CERTIFICATE THAT NEEDS TO BE REPLACED
Card Cert.
OSHA 500 Trainer Course in OSHA Standards for the Construction Industry – 1 card maximum
OSHA 502 Update for Construction Industry Outreach Trainer - 1 card maximum
N/A OSHA 510 Occupational Safety & Health Standards for the Construction Industry
OSHA 501 Trainer Course in OSHA Standards for General Industry – 1 card maximum
OSHA 503 Update for General Industry Outreach Trainer –1 card maximum
N/A OSHA 511 Occupational Safety & Health Standards for General Industry
N/A OSHA 10-Hour Construction Industry Course – Note: If training took place more than 3 years ago, no replacement cards will be issued.
N/A OSHA 30-Hour Construction Industry Course – Note: If training took place more than 3 years ago, no replacement cards will be issued.
N/A OSHA 10-Hour General Industry Course – Note: If training took place more than 3 years ago, no replacement cards will be issued.
N/A OSHA 30-Hour General Industry Course – Note: If training took place more than 3 years ago, no replacement cards will be issued.
IF YOU ARE REQUESTING CERTIFICATES OR A CARD/s FOR A COURSE NOT LISTED ABOVE, PLEASE ENTER INFORMATION BELOW.
Total # of Replacement Cards Total Cost of Replacement Cards Total # of Replacement Certificates Total Cost of Replacement Certificates
Requested $25.00 PER CARD Requested $25.00 PER CERTIFICATE
$ $
TO ORDER REPLACEMENT CARDS
ON-LINE BY FAX: BY PHONE: BY MAIL:
with payment to:
with credit card at with credit card or P.O. copy with credit card Northern Illinois University
c/o Outreach Services
www.nsec.niu.edu Fax to (815) 753-6900 Call (800) 656-5317 NSEC Registrar
DeKalb, IL 60115-2860
PAYMENT OPTIONS
Credit Card
VISA MASTERCARD DISCOVER AMEX AMOUNT: $
Payment: $
Name on Credit Card:
Expiration Date:
(Please print)
Card Holder’s Signature:
Credit Card #
Check Enclosed:
(Payable to Northern Illinois University) Check # Amount
$
Company Purchase Please fax a copy of the P.O. at time of
FEIN# (Required for
Order #: registration or attach to this application form and P.O.#
processing and billing)
mail.
Requestor’s
Signature:
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COURSE INFORMATION
Dates of Course:
Student
1 Original Card #:
Name:
Student
2 Original Card #:
Name:
Student
3 Original Card #:
Name:
Student
4 Original Card #:
Name:
Student
5 Original Card #:
Name:
Student
6 Original Card #:
Name:
Student
7 Original Card #:
Name:
Student
8 Original Card #:
Name:
Student
9 Original Card #:
Name:
Student
10 Original Card #:
Name:
Student
11 Original Card #:
Name:
Student
12 Original Card #:
Name:
Student
13 Original Card #:
Name:
Student
14 Original Card #:
Name:
Student
15 Original Card #:
Name:
Student
16 Original Card #:
Name:
Student
17 Original Card #:
Name:
Student
18 Original Card #:
Name:
Student
19 Original Card #:
Name:
Student
20 Original Card #:
Name:
OFFICE USE ONLY:
REQUEST APPROVED: YES NO APPROVED BY:
REPLACEMENT CARDS /
YES NO DATE SENT:
CERTIFICATES SENT
COMMENTS:
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