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: info@erplus.com

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: info@erplus.com

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: info@erplus.com

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: info@erplus.com

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