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REGISTRATION FORM / CSCCB COURSES Due to renovations, Effective Immediately - Non-Members must submit Form via email to: [email protected]. Members are required to register online through the portal. No Refunds for Courses Taken ( ) - Company Name Company Authorization Contact # Trainee Name Last First SSN / Self Pay: YES □ NO □ / / Member Number Non-Member Number If yes checked see attached Credit Card Form Date of Training Entered By CSC personnel Phone: 361-289-5856 **Call to Schedule BASIC PLUS Basic Orientation Plus Basic Orientation Plus Refresher General Orientation Corpus SITE SPECIFIC Citgo Site Citgo Alky Citgo Confined Space Attendant Citgo Fringe Citgo Fringe Exempt Citgo Gasket Removal Citgo Permit Training Citgo Welding Fumes Chemours Site Elementis Chromium Site Elementis Chromium Fringe LyondellBasell Site LyondellBasell Site Spanish LyondellBasell Pipeline Flint Hills Site Specific Flint Hills Alky Flint Hills Fringe Flint Hills Fringe Outside Site Flint Hills Safe Work Practices Flint Hills Safety Lead Flint Hills LOTOX Gravity Midstream CC Celanese Bishop Site Celanese APB Project BASF Icebreaker Project (HCBASF) Celanese Permit Receiver Celanese Unit Overview Javelina Site OXEA Unit Bishop Site Oxychem - Ingleside Site Oxychem - Ingleside Spanish Valero Corpus Christi Site Valero Corpus Christi Spanish Valero Three Rivers Site Valero Three Rivers Alky Valero Three Rivers Fringe Valero Three Rivers RCRA NON-OWNER SITE SPECIFIC Safe Secure Stay at Buckeye Buckeye Texas HUB Buckeye Texas Processing Chapman Ranch Wind Farm (RESCWF) DCP Field Ops DCP Field Ops Spanish DCP Gulf Plains DCP Gulf Plains Spanish DCP Gulf Plains Truck Loading DCP Gulf Plains Truck Loading Spanish DCP La Gloria DCP La Gloria Spanish DCP La Gloria Truck Loading DCP La Gloria Truck Loading Spanish DCP Three Rivers DCP Three Rivers Spanish DCP Three Rivers Truck Loading DCP Three Rivers Truck Loading Spanish Magellan Midstream Partners - CC South Cross Energy SXW or SXWE Voestalpine Site Safety Orient. (VSSO1) Voestalpine Site & Safety Lead (VA) SPECIALTY COURSES ACM Gasket Removal Accident Investigation Asbestos Awareness Benzene Training Bloodborne Pathogens Confined Space Driver Safety Electrical Safety Fall Protection Fire Watch Attendant **Standard First Aid / CPR AED **Forklift Training Formaldehyde Training Globally Harmonized Sys. H2S Refinery Trained Hand & Power Tool Hazard Communication Heat Stress Awareness Hexavalent Chromium Lead Awareness Lifting Safety **Man Lift /Aerial Lift **Man Lift & Scissor Lift Marsec **MSHA 8 Hr. Refresher **OSHA 10 hr. Construction Refractory Ceramic Fiber Respirator Safety Training Scaffold User Spanish Orientation Supplied Air Attendant Trenching & Excavation Welding Training NEW HIRE/COMPANY ORIENTATIONS New Hire Coonrod Electric New Hire Brace Industries New Hire Brace Industries Spanish Scott New Hire QualSpec Rabalais I&E Constructors SAGE Environmental Tech. MEDICAL SERVICES Audiometric Testing Audiometric w/Data mgt. Medical Questionnaire Pulmonary w/Med Quest. Pulmonary Function Test Respirator Fit REPLACEMENT BADGE CSC Replacement Badge $5.00

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Page 1: REGISTRATION FORM / CSCCB COURSES

REGISTRATION FORM / CSCCB COURSES Due to renovations, Effective Immediately - Non-Members must submit Form via email to: [email protected]. Members are required to register online through the portal. No Refunds for Courses Taken

( ) - Company Name Company Authorization Contact #

Trainee Name Last First SSN

/ Self Pay: YES □ NO □ / / Member Number Non-Member Number If yes checked see attached Credit Card Form Date of Training

Entered By CSC personnel

Phone: 361-289-5856 **Call to Schedule

BASIC PLUS Basic Orientation Plus Basic Orientation Plus Refresher General Orientation Corpus

SITE SPECIFIC Citgo Site Citgo Alky Citgo Confined Space Attendant Citgo Fringe Citgo Fringe Exempt Citgo Gasket Removal Citgo Permit Training Citgo Welding Fumes Chemours Site Elementis Chromium Site Elementis Chromium Fringe LyondellBasell Site LyondellBasell Site Spanish LyondellBasell Pipeline Flint Hills Site Specific Flint Hills Alky Flint Hills Fringe Flint Hills Fringe Outside Site

Flint Hills Safe Work Practices Flint Hills Safety Lead Flint Hills LOTOX Gravity Midstream CC Celanese Bishop Site Celanese APB Project BASF Icebreaker Project (HCBASF) Celanese Permit Receiver Celanese Unit Overview Javelina Site OXEA Unit Bishop Site Oxychem - Ingleside Site

Oxychem - Ingleside Spanish Valero Corpus Christi Site Valero Corpus Christi Spanish Valero Three Rivers Site Valero Three Rivers Alky Valero Three Rivers Fringe Valero Three Rivers RCRA

NON-OWNER SITE SPECIFIC Safe Secure Stay at Buckeye Buckeye Texas HUB Buckeye Texas Processing Chapman Ranch Wind Farm (RESCWF)

DCP Field Ops DCP Field Ops Spanish DCP Gulf Plains DCP Gulf Plains Spanish DCP Gulf Plains Truck Loading

DCP Gulf Plains Truck Loading Spanish

DCP La Gloria DCP La Gloria Spanish DCP La Gloria Truck Loading DCP La Gloria Truck Loading Spanish DCP Three Rivers DCP Three Rivers Spanish DCP Three Rivers Truck Loading DCP Three Rivers Truck Loading Spanish Magellan Midstream Partners - CC

South Cross Energy SXW or SXWE

Voestalpine Site Safety Orient. (VSSO1)

Voestalpine Site & Safety Lead (VA)

SPECIALTY COURSES ACM Gasket Removal Accident Investigation Asbestos Awareness Benzene Training

Bloodborne Pathogens Confined Space Driver Safety Electrical Safety Fall Protection Fire Watch Attendant **Standard First Aid / CPR AED **Forklift Training Formaldehyde Training Globally Harmonized Sys. H2S Refinery Trained Hand & Power Tool Hazard Communication Heat Stress Awareness Hexavalent Chromium Lead Awareness Lifting Safety **Man Lift /Aerial Lift

**Man Lift & Scissor Lift Marsec **MSHA 8 Hr. Refresher **OSHA 10 hr. Construction Refractory Ceramic Fiber Respirator Safety Training Scaffold User Spanish Orientation Supplied Air Attendant Trenching & Excavation Welding Training

NEW HIRE/COMPANY ORIENTATIONS

New Hire Coonrod Electric

New Hire Brace Industries

New Hire Brace Industries Spanish Scott New Hire

QualSpec

Rabalais I&E Constructors SAGE Environmental Tech.

MEDICAL SERVICES

Audiometric Testing Audiometric w/Data mgt. Medical Questionnaire Pulmonary w/Med Quest. Pulmonary Function Test Respirator Fit

REPLACEMENT BADGE CSC Replacement Badge $5.00

Page 2: REGISTRATION FORM / CSCCB COURSES

Credit Card Authorization FormOct 2016

Cont

ractors Safety Council of the Coastal Bend, Inc.Mailing Address- P.O. Box 23066 Corpus Christi TX. 78403

Phone 361-289-5856Physical Address- 7433 Leopard St. Corpus Christi, Texas 78409

Admin. Fax: 361-289-6557 (Membership/Invoice Only)Registration Email: [email protected] www.csccb.org

Please completely fill out the following information to allow Contractors Safety Council of the Coastal Bend Inc. to apply charges on your credit card. Email Form for CLASSES to: [email protected]. For MEMBERSHIP or INVOICES Fax: 361-289-6557.

Member Non-Member

Member Number Company Name

Payment Amount: PurposeBadge or Classes Email Form to [email protected] Visa

Master Card

Discover

American Express

Card Holders Information Please print clearly Note all information as it appears on the credit card

First

Middle

Last

Card Number:

Expiration Date: Security Code:

Security code is the three digit number noted on back of card. Four digit number on front of American Express

Badge – List name and SSN Below

Name: SSN:

Classes – List Trainees Name and Email Registration Form

Name:

For Membership or Invoices Fax Form to 361-289-6557 or

Membership - Email to: [email protected]

Invoice - Email to: [email protected]

Please Place Credit Card Here and copy before sending

Credit Card Billing Information

Street/P.O.

City

State Zip

Phone Number

E-Mail

I agree and authorize that my liability for this bill is not waived and agree to be held personally responsible in the event that the

indicated person, company, or association fails to pay for any portion or the full amount of these charges.

Card Holder Signature: Date:__ ____ ____ ___

Invoice Number/s


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