Cal/OSHA Excavation Competent Person Examination Request Form ?· Cal/OSHA Excavation Competent Person…

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  • Form # 720-166 Rev 02-09-16 (Cal-OSHA Request Form).doc Page 1 of 4

    Cal/OSHA Excavation Competent Person Examination Request Form

    This request should be submitted no later than three (3) weeks before examination date.

    It is the requesting entitys responsibility to notify each applicant of the time and date of the

    examination.

    A minimum of 10 applicants is required for an examination.

    Please fax to Ines Perez or E-mail to ines@nationalitc.com.

    Please fill in the information below:

    Have all applicants completed an 8-hour course? Yes No

    Test packets will not be mailed to P.O. Boxes

    Location of Examination:

    Address:

    City, State, Zip:

    Contact Person: Position:

    Phone No: Fax No:

    E-mail:

    Date of Examination: Number of Examinees:

    Proctors Name:

    Address:

    City, State, Zip:

    Cell Phone No: Fax No.

    E-mail:

    *Need NITC to find a proctor: Yes No

  • Form # 720-166 Rev 02-09-16 (Cal-OSHA Request Form).doc Page 2 of 4

    Please print or type all the information (completely) for each applicant as you would like it to appear on their certification and fax to N.I.T.C. (213) 351-7632.

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Required Fields

  • Form # 720-166 Rev 02-09-16 (Cal-OSHA Request Form).doc Page 3 of 4

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Required Fields

  • Form # 720-166 Rev 02-09-16 (Cal-OSHA Request Form).doc Page 4 of 4

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Name: *Name:

    *Address: *Address:

    *City: *City:

    *State: *Zip: *State: *Zip:

    *S.S. # (last 6): XXX- *S.S. # (last 6): XXX-

    Phone #: Phone #:

    E-mail: E-mail:

    *Local Union No.: *Local Union No.:

    *Required Fields

    Location of Examination: Address: City State Zip: Contact Person: Position: Phone No: Fax No: Email: Date of Examination: Number of Examinees: Have all applicants completed an 8hour course Yes: No: Proctors Name: Address_2: City State Zip_2: Cell Phone No: Fax No_2: Email_2: Need NITC to find a proctor: Name: Name_2: Address_3: Address_4: City: City_2: SS last 6 XXX: SS last 6 XXX_2: Phone: Phone_2: Email_3: Email_4: Local Union No: Local Union No_2: Name_3: Name_4: Address_5: Address_6: City_3: City_4: SS last 6 XXX_3: SS last 6 XXX_4: Phone_3: Phone_4: Email_5: Email_6: Local Union No_3: Local Union No_4: Name_5: Name_6: Address_7: Address_8: City_5: City_6: SS last 6 XXX_5: SS last 6 XXX_6: Phone_5: Phone_6: Email_7: Email_8: Local Union No_5: Local Union No_6: Name_7: Name_8: Address_9: Address_10: City_7: City_8: SS last 6 XXX_7: SS last 6 XXX_8: Phone_7: Phone_8: Email_9: Email_10: Local Union No_7: Local Union No_8: Name_9: Name_10: Address_11: Address_12: City_9: City_10: SS last 6 XXX_9: SS last 6 XXX_10: Phone_9: Phone_10: Email_11: Email_12: Local Union No_9: Local Union No_10: Name_11: Name_12: Address_13: Address_14: City_11: City_12: SS last 6 XXX_11: SS last 6 XXX_12: Phone_11: Phone_12: Email_13: Email_14: Local Union No_11: Local Union No_12: Name_13: Name_14: Address_15: Address_16: City_13: City_14: SS last 6 XXX_13: SS last 6 XXX_14: Phone_13: Phone_14: Email_15: Email_16: Local Union No_13: Local Union No_14: Name_15: Name_16: Address_17: Address_18: City_15: City_16: SS last 6 XXX_15: SS last 6 XXX_16: Phone_15: Phone_16: Email_17: Email_18: Local Union No_15: Local Union No_16: Name_17: Name_18: Address_19: Address_20: City_17: City_18: SS last 6 XXX_17: SS last 6 XXX_18: Phone_17: Phone_18: Email_19: Email_20: Local Union No_17: Local Union No_18: Name_19: Name_20: Address_21: Address_22: City_19: City_20: SS last 6 XXX_19: SS last 6 XXX_20: Phone_19: Phone_20: Email_21: Email_22: Local Union No_19: Local Union No_20: Name_21: Name_22: Address_23: Address_24: City_21: City_22: SS last 6 XXX_21: SS last 6 XXX_22: Phone_21: Phone_22: Email_23: Email_24: Local Union No_21: Local Union No_22: Name_23: Name_24: Address_25: Address_26: City_23: City_24: SS last 6 XXX_23: SS last 6 XXX_24: Phone_23: Phone_24: Email_25: Email_26: Local Union No_23: Local Union No_24: Text1: Text2: Text3: Text4: Text5: Text6: Text7: Text8: Text9: Text10: Text11: Text12: Text13: Text14: Text15: Text16: Text17: Text18: Text19: Text20: Text21: Text22: Text23: Text24: Text25: Text26: Text27: Text28: Text29: Text30: Text31: Text32: Text33: Text34: Text35: Text36: Text37: Text38: Text39: Text40: Text41: Text42: Text43: Text44: Text45: Text46: Text47: Text48:

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