Workers' Compensation and Workplace Safety
Webinar 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:
Successful completion of a TEST immediately following the class is required for processing of the CEU credit.
4. PLEASE IDENTIFY THE WEBINAR(s) FOR WHICH YOU ARE REGISTERING:
Workers’
Compensation
Workers’
Compensation
Workers’
Compensation
Workers’
Compensation
Workers’
Compensation
Workers’
Compensation
July 18, 2018
August 22, 2018
September 12, 2018
October 17, 2018
November 14, 2018
December 19, 2018
2:00 –
3:00 pm
2:00 –
3:00 pm
2:00 –
3:00 pm
2:00 –
3:00 pm
2:00 –
3:00 pm
2:00 –
3:00 pm
Workplace
Safety
Workplace
Safety
Workplace
Safety
Workplace
Safety
Workplace
Safety
Workplace
Safety
July 19, 2018
August 23, 2018
September 13, 2018
October 18, 2018
November 15, 2018
December 20, 2018
2:00 –
3:00 pm
2:00 –
3:00 pm
2:00 –
3:00 pm
2:00 –
3:00 pm
2:00 –
3:00 pm
2:00 –
3:00 pm
A separate form is required for each person attending the webinar, although, you may submit one form for multiple webinars.
Please write clearly and complete the form as applicable.
June 2018