Osha Training Form - PDF

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					                           OSHA Training Institute Region IX Education Center
                                  University of California, San Diego

                                               Replacement Card Form
 This form is designated for students who have completed their Train-the-Trainer course at the UCSD OSHA
Training Institute or for those who have been trained (in a 10- or 30-Hour OSHA course) by a student who has
          completed this training at the UCSD OSHA Training Institute and need a replacement card.
           Fill out your name, address, city, state and zip code.
           Check the appropriate box for the card that needs to be replaced.
           For Trainer Cards: Fill in the date, section ID (this is the 5-digit number you used when you
            registered for the class) and location of the course.
            For 10- or 30-Hour Cards: Complete the section designated for 10- and 30-Hour card replacements.
           Along with this completed form, please send $25.00 per card replacement to:
            OSHA Training Institute Region IX Education Center
            University of California, San Diego
            8950 Villa La Jolla Drive Suite C215
            La Jolla CA 92037

   Name: ______________________________________________________________________________

    Address: ____________________________________________________________________________

    City: _____________________________ State: ____________________ Zip Code: _______________

    PID: __________________________________ Daytime Phone Number: _______________________

   Check each card that needs to be replaced:
       OSHA #500: Trainer Card for Construction Industry
       OSHA #501: Trainer Card for General Industry
       OSHA #502: Update for Construction Industry Outreach Trainers
       OSHA #503: Update for General Industry Outreach Trainers
       OSHA 10-Hour General Industry Course
       OSHA 10-Hour Construction Industry Course
       OSHA 30-Hour General Industry Course
       OSHA 30-Hour Construction Industry Course

   Dates of Course: _________________________________ Section ID: __________________________
    Location of Course: ___________________________________________________________________
    For 10- and 30-Hour card replacements ONLY:
    NOTE: This applies only to courses taken after October 1, 2003.

    Name of Trainer: _____________________________________________________________________
    Dates of Course: __________________________ Location of Course: __________________________

   Payment                               Name that appears on the card: ______________________________________

            Please check the              Credit Card Number: _______________________________________________
            appropriate box:              Expiration Date: _____________Cardholder’s Phone_____________________
           Check
           Money Order                   Signature: _______________________________________________________
           MasterCard
           Visa
                                           TOTAL ENCLOSED: $_____________
           Discover                      *Make checks payable to “UC Regents”                    Thank you!

Description: Osha Training Form document sample