Workers' Compensation and Workplace Safety
Seminar Registration Form
The form may be e-mailed to [email protected] or faxed to 239-338-2786.
1.
NAME OF INDIVIDUAL ATTENDING
First
(As you want it to appear on the Certificate of Completion)
Initial Last
Phone #: -
Suffix(Jr. Sr.)
2. BUSINESS INFORMATION:
Business Name:
Street Address:
City:
State:
Zip Code:
-
Fax #:
-
-
E-mail Address:
3.
LICENSE INFORMATION :
(For CEU reporting to the Department of Business & Professional Regulation; CILB & ECLB licenses only; 1 CEU awarded per course)
Construction Industry Licensing Board
Electrical Contractors Licensing Board
CILB Provider Number: 0004354
Workers’ Comp # 10118; Workplace Safety # 10630
Type of License:
Name of License Holder:
ECLB Provider Number: 0004684
Workers’ Comp # 8264; Workplace Safety # 8263
License #:
Eff. Date:
Exp. Date:
4. PLEASE IDENTIFY THE SEMINAR FOR WHICH YOU ARE REGISTERING:
Date
July
17 th ,
City
2018
Jacksonville
July 25 th , 2018 Ft. Myers
August 15 th , 2018 Miami
August 15 th , 2018 Tampa
September 12 th , 2018 Orlando
September 25 th , 2018 Ft. Lauderdale
October 18 th , 2018 Jacksonville
November 8 th , 2018 Miami
November 20 th , 2018 Tampa
December 11 th , 2018 Tallahassee
December 19 th , 2018 Orlando
Location
Jacksonville Regional Service Center, 921 N. Davis Street, Building B, Suite 301,
Jacksonville, FL 32209
State of Florida Office Building, 2295 Victoria Avenue, Room 165 C & D,
Ft. Myers, FL 33901
State of Florida Rhode Building, 401 NW 2nd Avenue., South Tower, Room N-423,
Miami, FL. 33128
State of Florida Park Trammel Building, 1313 North Tampa Street, Suite 605,
Tampa, FL 33603
State of Florida Hurston Building, North Tower, 400 West Robinson Street, N 101,
Orlando, FL 32801
1400 W. Commercial Blvd, Ste. 195, Ft. Lauderdale, FL 33309
Jacksonville Regional Service Center, 921 N. Davis Street, Building B, Suite 301,
Jacksonville, FL 32209
State of Florida Rhode Building, 401 NW 2nd Avenue, South Tower, Room N-106,
Miami, FL 33128
State of Florida Park Trammel Building, 1313 North Tampa Street, Suite 605,
Tampa, FL 33603
Division of Workers’ Compensation, 2012 Capital Circle SE, Hartman Building, Room 102,
Tallahassee, FL 32399
State of Florida Hurston Building, North Tower, 400 West Robinson Street, N 101,
Orlando, FL 32801
A separate form is required for each person attending the session.
Please write clearly and complete the form as applicable.
June 2018