Embed Size (px)
Citation preview
Safety is Our Passion! 230-11120 Horseshoe Way, Richmond, B.C., V7A 5H7 Phone: 604-275-9070 Fax: 604-275-9074
Web: www.erplus.com Email: [email protected]
REGISTRATIONLETTER
CONSTRUCTIONSAFETYOFFICERCERTIFICATE(CSO-200)TradeSafetyCoordinator(TSC-200-211)/ConstructionSafetyOfficer(CSO-200-212)
DearConstructionSafetyOfficerCertificateParticipant:WearepleasedtowelcomeyoutoourConstructionSafetyOfficerCertificate(CSO-200)whichconsistsofTradeSafetyCoordinatorCourse(TSC-200-211)andtheConstructionSafetyOfficerCourse(CSO-200-212).IncludedinthispackageyouwillfindthefollowingformsthatmustbecompletedandreturnedpriortoIndustrialMarineTrainingandAppliedResearchCentre(IMTARCcommencementofyourtraining):
• StudentRegistrationForm• StatementofFitnessForm• StudentLetterofDeclaration
Inordertomeetthecriteriathathasbeensetoutbythegoverningbodythatoverseesthecertificationprocess,thefollowingprerequisitesMUSTbemetpriortoenteringtheprogram:
1. PhysicalfitnessverificationthroughaStatementofFitnesstobecompletedandreturnedtoIndustrialMarineTrainingandAppliedResearchCentre(IMTARC).(foundwiththisregistrationpackage)
2. Minimumageis18yearsold(pleaseprovideacopyofvalidID);
3. KnowledgeandcommandoftheEnglishlanguagetothelevelofsuccessfullycompletingthecoursereadingsandassignments.
Proofthatthecandidatemeetsallprerequisitesshallbepresentedbeforecompletioncertificateis
issuedbyERPlusRiskManagementGroupInc.
Ifyouhaveanyquestions,orwouldlikefurtherinformation,pleasecallIndustrialMarineTrainingandAppliedResearchCentre(IMTARC)at1-778-265-5005oremailatcontact@imtarc.comorERPlusRiskManagementGroupInc.at1-604-275-9070oremailatinfo@erplus.com.Sincerely,ERPlusRiskManagementGroupInc.
Safety is Our Passion! 230-11120 Horseshoe Way, Richmond, B.C., V7A 5H7 Phone: 604-275-9070 Fax: 604-275-9074
Web: www.erplus.com Email: [email protected]
STUDENTREGISTRATIONFORMSTUDENTINFORMATION
Surname:
First:
Middle: qMr.
qMrs.qMs.qMiss
Isthisyourlegalname? Ifnot,whatisyourlegalname? (Formername): Birthdate:
YY/MM/DD
Age: Sex:qMqFqYes qNo
MailingAddressandContactInformation:Allcorrespondencewillbemailedtothisaddress.PleasenotifyERPlusRiskManagementGroupInc.ofanychanges.Pleaseprovideyouremailaddressandatleastonephonenumbersowecancontactyouintheeventofacourseschedulechangeorcancellation.Streetaddress: HomePhoneno.: CellPhoneno.:
P.O.box: City: Province: PostalCode:
EmailAddress: RelationshiptoStudent: EmergencyContactphoneno.:
COURSELISTConstructionSafetyOfficer(CSO)CertificateCSO-200TradeSafetyCoordinator(TSC)Course(CSOPart1)-CSO-200-211ConstructionSafetyOfficer(CSO)Course(CSOPart2)–CSO-200-212
qqq
Location:
ProgramDate:
Note:InordertoreceivetheCertificateofCompletionfortheConstructionSafetyOfficerCourseandbeeligibleforapplicationtotheASTTBCfortheConstructionSafetyOfficerDesignation,studentsarerequiredtosuccessfullycompleteboththeTradeSafetyCoordinatorandtheConstructionSafetyOfficercourses.
PAYMENTMETHOD
qCash qInvoice–CorporatePORequired qVisa qMasterCard qCertifiedCheque
CardNumber:
ExpiryDate:MM/YYYY
SecurityCode: NameonCard:
OFFICEUSEONLYPaymentReceived?qYesqNoYYYY/MM/DD
CorporateInvoice#: CorporatePO#:
Safety is Our Passion! 230-11120 Horseshoe Way, Richmond, B.C., V7A 5H7 Phone: 604-275-9070 Fax: 604-275-9074
Web: www.erplus.com Email: [email protected]
CONSTRUCTIONSAFETYOFFICERCERTIFICATE(CSO-200)
StatementofFitnessSurname: Givenname(s)infull: Mr.
Mrs.Ms.Miss
qqqq
Dateofbirth:yyyy–mm-dd
Mailingaddress:
City/Province: PostalCode:
SIN#
CareCard#
Answerallthefollowingquestionshonestlyandtruthfullyregardinganymedicalconditions.Formoreinformationonthestatementoffitness,contactERPlusRiskManagementGroupInc.IftheanswertoanyofthefollowingquestionsisYES,aMedicalCertificate,completedbyaphysician,mustbeprovidedbeforethecoursestarts.ThisformcanbeobtainedfromERPlusRiskManagementGroupInc.uponrequest.Diseaseconditions–Istheremedicalevidenceand/orhistoryof:DiabetesSeizuredisorderCommunicablediseaseHernia
YesqNoqYesqNoqYesqNoqYesqNoq
RespiratorydiseaseHeartdiseaseMultiplesclerosisOther
YesqNoqYesqNoqYesqNoqYesqNoq
Alcoholorsubstanceabuse-Haveyouexperiencedanyproblemsintheprevious12months,relativetotheoveruseand/oraddictiontoalcohol,recreationalorprescriptiondrugs,and/orover-the-countermedications?
YesqNoqPsychologicaland/oremotionalillness–HaveyouexperiencedanypsychologicaloremotionalepisodeswhichcouldprecludeyoufromperformingthedutiesofaTSC/CSO?
YesqNoqVisualacuity-Willyou(withappropriatevisualcorrection,ifrequired)beabletoobserveahazardorincidentfromadistance,assessandrespond?
YesqNoqHearingacuity–Willyou(withappropriatehearingcorrection,ifrequired)beabletohearandrespondtoahazardorincidentonaconstructionsite?
YesqNoqPhysicalfitness–Doyouhaveanyphysicalconditionsthatwouldlimityoufromclimbingroughterrainsuchassteepbanks,steepexcavations,orhigherelevationstoprovideTSC/CSOfunctions?
YesqNoqCandidate’sName(pleaseprint):
Candidate’sSignature: Date:(yyyy-mm-dd)
Safety is Our Passion! 230-11120 Horseshoe Way, Richmond, B.C., V7A 5H7 Phone: 604-275-9070 Fax: 604-275-9074
Web: www.erplus.com Email: [email protected]
STUDENTINFORMATIONSurname:
First:
Middle: qMr.
qMrs.qMs.qMiss
Isthisyourlegalname? Ifnot,whatisyourlegalname? (Formername): Birthdate:
YY/MM/DD
Age: Sex:qMqF
qYes qNo
Streetaddress: HomePhoneno.: CellPhoneno.:
P.O.box: City: Province: PostalCode:
EmailAddress:
READTHEFOLLOWINGSTATEMENTSCAREFULLY
YES
NO
PROOFATTACHED
Iamminimumage18yearsoldatthecommencementofthisprogram(providecopyofphotoid)
q
q
q
IunderstandthatanycriminalconvictionswillneedtobedisclosedandpresentedtotheASTTBCboardforconfidentialreviewshouldIdecidetopursuetheASTTBCdesignationofCSO
q q q
Ihavecompletedsecondaryschoolorequivalent q q q
IhavecompletedandsubmittedtheStatementofFitness(MedicalCertificateofFitnesstobecompletedbyphysicianisrequiredinthecasewhereyouhavedeclared“yes”toanyofthequestionsontheStatementofFitness.TheformcanbeobtainedfromERPlusuponrequest).
q q q
Iamcompetenttoread,write,understandandspeakcoherentlyoncourse-relatedtopics q q q
STUDENTDECLARATION
IherebydeclarethatIhavereadandunderstandthestatements,prerequisitesandpoliciesaslaidoutaboveandintheTradeSafetyCoordinator(TSC-200-211)and/orConstructionSafetyOffice(CSO-200-212)StudentPolicyManuals.IunderstandthatERPlusRiskManagementGroupInc.hastherighttorefuseacceptanceintotheConstructionSafetyOfficerCertificateifIdonotmeettheadmissionrequirementslistedabove.Iunderstandthatnorefundswillbeissuedforrightfuldismissal/expulsionfromthisprogram.StudentName(Printed): Date:
(yyyy-mm-dd)StudentSignature:
OFFICEUSEONLY
ApplicationreviewedYesqNoq(yyyy-mm-dd)
SupportdocumentationreceivedYesqNoq
