Signature: Date:
Complete the form and sign. Return form, and required documentation at least 2 weeks
prior to the start of class by email to
otc@clpccd.org, fax to (925) 460-0133, or by mail. If you have any questions, please contact us at (866) 936-OSHA (6742).
Full Legal Name:
(please print legibly)
City:
Email:
(enter date)
Mailing Address:
State: Zip: Phone:
I would like to register for the OSHA 503 class starting on:
Class Location:
OSHA 503 Prerequisites
I have included the following documents:
Copy of current outreach trainer card
Note: On January 1, 2019, the 90-day grace period was eliminated. If your card is expired, OSHA 501 must be retaken.
Additionally, if you have not taken the OSHA 511 standards course within the last 7 years, you will also be required to retake
it.
Copy of government-issued photo identification (i.e. drivers’ license, passport)
Please answer questions, sign and date below
Have you previously been subject to revocation, suspension, or probation by OSHA? Yes No
If you responded yes above, please attach all OSHA correspondence related to the investigation.
I certify that the information I have included herein and submitted to the OTI Education Center is true and accurate. I understand
that I will be subject to immediate dismissal from the OSHA Outreach Training Program if information provided herein is not true and
correct. I further understand that providing false information herein may subject me to civil and criminal penalties under Federal law,
including 18 U.S.C. 1001 and section 17(g) of the Occupational Safety and Health Act, 29 U.S.C. 666 (g), which provides criminal
penalties for making false statements or representations in any document filed pursuant to that Act.
COURSE PREREQUISITE AND EXPERIENCE REQUIREMENT ELIGIBILITY STATEMENT
OSHA 503 - Update for General Industry Trainers
Other (Please specify)
Applicant did not submit proof of applicable certification or degree
Applicant did not include transcripts
Applicant did not sign form
If not approved, please indicate reason:
Applicant did not demonstrate completion of the prerequisite course
within the previous seven years
Applicant did not demonstrate the required years of experience
Approving Official Signature
Approving Official Title Approving Official Name
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signature
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