Fillable Safety Associate Certificate Request Form Construction Industry (OSHA Training Institute Education Center)

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Safety Associate Certificate Request Form Construction Industry (OSHA Training Institute Education Center)

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Safety Associate Certificate Request Form – Construction Industry
• Requires 6 OSHA courses - A minimum of 4 courses must have been taken with Chabot-Las Positas
Community College District – OSHA Training Institute Education Center.
• Only OSHA numbered courses taken at an OSHA Training Institute Education Center will be accepted.
• Copies of certificates must be provided with request; please do not submit until all courses are complete.
• Applicant is responsible for tracking their completion progress and submitting this application form when
al
l requirements have been met.
• All courses applied towards certificates must have been taken within the previous 5 years.
Name: Date Requested:
Street Address:
City: State: Zip:
Phone Number: Email:
Required Courses:
E
lective Courses (choose 3):
OSHA 2015: Hazardous Materials
OSHA 3095: Electrical Standards
OSHA 3015: Excavation, Trenching, & Soil Mechanics
OSHA 2264: Permit-Required Confined Space Entry
OSHA 3115: Fall Protection
Safety Inspection Techniques (OTC 308)
OSHA 5109: Cal/OSHA Standards for Construction
A
dditional Electives – Short Courses
(3 short courses count as one (1) elective [maximum allowed is 6]):
O
SHA4you.com (866)
936
-OSHA (6742) otc@clpccd.org
OSHA 510: OSHA Standards for Construction Industry
OSHA 7505: Intro to Incident (Accident) Investigation
OSHA 7845: Recordkeeping Rule Seminar
OSHA 7100: Intro to Machinery & Machine Guarding
OSHA 7210: Pandemic Illness Preparedness
OSHA 7105: Intro to Evac. & Emergency Planning
OSHA 7215: Silica in Construction, Maritime, & General Industry
OSHA 7120: Intro to Combustible Dust Hazards
OSHA 7300: U. OSHA’s Permit-Required Confined Space Std.
OSHA 7115: Lockout/Tagout
OSHA 7400: Noise Hazards in Construction
OSHA 7205: Health Hazard Awareness
OSHA 7410: Managing Excavation Hazards
OSHA 7500: Intro to Safety & Health Management
Payment Information:
Payment information must be included to complete the registration process. Certificate fee is $99.00.
Enclosed is a check payable to Chabot-Las Positas Community College District – OSHA Training
Institute Education Center
Please charge the credit card provided below (you may also call our office at (866) 936-6742 to make
credit card payment)
C
redit Card Number Name on Credit Card Exp. Date
Billing Address City State Zip Code
S
ignature of Credit Card Holder Date Card Type
(Visa/M
asterCard/AMEX accepted)
Completed registration forms and payment can be submitted by:
Email: otc@clpccd.org
Fax: (925) 460-0133
Mail: 5860 Owens Dr, 3
rd
Floor, Pleasanton, CA 94588
OSHA4you.com (866) 936-OSHA (6742) otc@clpccd.org
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Safety Associate Certificate Request Form Construction Industry (OSHA Training Institute Education Center)

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Completed 17 July 2021

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