April 2011 OSHA Card Replacement form - DOC by Z5HN4T6E

VIEWS: 6 PAGES: 2

									                                                    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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