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Education Center - Rochester Institute of Technology

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Register now! Call toll-free 1-866-385-7470 ext. 2919 or visit www.rit.edu/osha for convenient online registration.<br />

Safety and Health Specialist Training<br />

Certificate Program Application<br />

<strong>Education</strong> <strong>Center</strong><br />

Personal Information<br />

Name<br />

Title<br />

Organization<br />

Organization Address<br />

City State Zip<br />

Telephone # Fax #<br />

E-mail address<br />

Application Fee<br />

There is a $25.00 application fee for each certificate.<br />

BY MAIL - with check, credit card, or P.O.:<br />

<strong>Rochester</strong> <strong>Institute</strong> <strong>of</strong> <strong>Technology</strong><br />

OSHA <strong>Education</strong> <strong>Center</strong><br />

31 Lomb Memorial Drive<br />

<strong>Rochester</strong>, NY 14623-5603<br />

BY FAX - with credit card or P.O. to: (585) 475-6292<br />

Payment Information<br />

Purchase order #<br />

Billing address:<br />

Please Circle: VISA / MasterCard<br />

FOR OFFICE USE ONLY<br />

_________________________<br />

Date Received<br />

__________________________<br />

Date Completed<br />

Card Number:<br />

Cardholder’s signature<br />

Exp. Date<br />

Construction Safety & Health Specialist Training Certificate<br />

4 required courses plus 3 electives<br />

Course Completion Date Location<br />

510 or 500 or 502*<br />

3010*<br />

3095*<br />

3110*<br />

521<br />

2225<br />

2264<br />

5600<br />

7205<br />

7400<br />

7405<br />

7410<br />

7500<br />

7505<br />

7600<br />

7845<br />

* Required<br />

General Industry Safety & Health Specialist Training Certificate<br />

3 required courses plus 3 electives<br />

Course Completion Date Location<br />

511 or 501 or 503*<br />

521*<br />

2045*<br />

2015<br />

2225<br />

2250<br />

2264<br />

3095<br />

7005<br />

7100<br />

7205<br />

7300<br />

7500<br />

7505<br />

7845<br />

* Required<br />

Please indicate the courses you have already completed, including training date and location. For classes taken at another training facility,<br />

you must include a copy <strong>of</strong> your certificate. Please note: Only two (2) courses from another training facility may be transferred.

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