Safety Foundations Certificate Request Form – Construction Industry
• Requires 4 OSHA courses - A minimum of 3 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;
online courses for the OSHA 30-hour requirement taken through an authorized provider 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
all 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:
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)
Credi
t Card Number Name on Credit Card Exp. Date
Bil
ling Address City State Zip Code
Sign
ature of Credit Card Holder Date Card Type
(Visa/MasterCard/AMEX acc
epted)
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
OSHA 30-Hour for the Construction Industry (OTC 107)
OSHA 7105: Evacuation and Emergency Planning
OSHA 7505: Introduction to Incident (Accident) Investigation
OSHA 7845: Recordkeeping Rule Seminar
click to sign
signature
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