cal/osha excavation competent person examination request form · cal/osha excavation competent...
TRANSCRIPT
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 entity’s 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 [email protected].
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:
Proctor’s 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