STUDENT REGISTRATION FORM

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COMPANY INFO
COMPANY NAME	MEMBER STATUS Member Non-Member
PHONE	CONTACT PERSON
FAX	EMAIL
ADDRESS 1	ADDRESS 2
CITY	STATE	ZIP

TRAINING DATE  /  /	TRAINING LOCATION LCSC - Charleston, SC WACSC - Wilmington, NC TACSC - High Point, NC CTC - Chocownity, NC
PO NUMBER	PAYMENT METHOD Cash Company Check Visa or Mastercard Invoice (Members Only)

STUDENT 1
FIRST NAME	LAST NAME
SSN	Or MASC Badge Number
BASIC ORIENTATION Basic Orientation Plus BOP Refresher Has Current BOP Has Current Reciprocal BOP Current BOP certification is a requirement for all sites listed below except GLW.	A BOP certification that has been expired by no more than sixty days is a requirement to take the Basic Orientation Plus Refresher (BOPR) course.

SITE SPECIFIC *ADM Southport requires that a background check (BCG) through LexisNexis be completed for each person before they are eligible to take the ADM site-specific course. **PCS Phosphate at Aurora requires completion of either a background check through DEPS or a current TWIC card. Check here: if a TWIC card will be presented at checkin for classes. ADM* Archer Daniels Midland Southport, NC ALCO Alcoa Charleston, SC BOS Robert S. Bosch Corp. Charleston, SC BPC BP Cooper River, SC BPIC Bushy Park Industrial Complex Charleston, SC DAK DAK Americas North & South Carolina DELL DELL Computers High Point, NC DOW Dow Corning High Point, NC DPTC DuPont Cooper River, SC ELEM Elementis Chromium Wilmington, NC FRTN Fortron Industries Wilmington, NC GLW Corning Glassworks Wilmington, NC HVNS Hovensa Refinery St. Croix, VI KSA KAO Specialties High Point, NC MWV Mead Westvaco Charleston, SC MUHA MUSC Hospital Authority Charleston, SC NVST Invista Wilmington, NC PCS** PCS Phosphate Aurora, NC RHO Rhodia Charleston, SC STOC Stockhausen, Inc. High Point, NC

OTHER COURSES Cold StressConfined Space Attendant/Hole WatchConfined Space EntryElectrical Safety for Non-QualifiedExcavation/TrenchingExcavation/Trenching Competent PersonFall ProtectionFire WatchForkliftHazard CommunicationHazard Materials 24-HourHazard Materials 40-HourHearing ConservationHeat StressHoliday SafetyLock Out/Tag OutOSHA 10-Hour for ConstructionRespiratory ProtectionScaffold UserScaffold Competent PersonWarehouseWork Zone

TIME 7:00am8:00am9:00am10:00am11:00amNoon1:00pm2:00pm

STUDENT 2
FIRST NAME	LAST NAME
SSN	Or MASC Badge Number
BASIC ORIENTATION Basic Orientation Plus BOP Refresher Has Current BOP Has Current Reciprocal BOP Current BOP certification is a requirement for all sites listed below except GLW.	A BOP certification that has been expired by no more than sixty days is a requirement to take the Basic Orientation Plus Refresher (BOPR) course.

SITE SPECIFIC *ADM Southport requires that a background check (BCG) through LexisNexis be completed for each person before they are eligible to take the ADM site-specific course. **PCS Phosphate at Aurora requires completion of either a background check through DEPS or a current TWIC card. Check here: if a TWIC card will be presented at checkin for classes. ADM* Archer Daniels Midland Southport, NC ALCO Alcoa Charleston, SC BOS Robert S. Bosch Corp. Charleston, SC BPC BP Cooper River, SC BPIC Bushy Park Industrial Complex Charleston, SC DAK DAK Americas North & South Carolina DELL DELL Computers High Point, NC DOW Dow Corning High Point, NC DPTC DuPont Cooper River, SC ELEM Elementis Chromium Wilmington, NC FRTN Fortron Industries Wilmington, NC GLW Corning Glassworks Wilmington, NC HVNS Hovensa Refinery St. Croix, VI KSA KAO Specialties High Point, NC MWV Mead Westvaco Charleston, SC MUHA MUSC Hospital Authority Charleston, SC NVST Invista Wilmington, NC PCS** PCS Phosphate Aurora, NC RHO Rhodia Charleston, SC STOC Stockhausen, Inc. High Point, NC

OTHER COURSES Cold StressConfined Space Attendant/Hole WatchConfined Space EntryElectrical Safety for Non-QualifiedExcavation/TrenchingExcavation/Trenching Competent PersonFall ProtectionFire WatchForkliftHazard CommunicationHazard Materials 24-HourHazard Materials 40-HourHearing ConservationHeat StressHoliday SafetyLock Out/Tag OutOSHA 10-Hour for ConstructionRespiratory ProtectionScaffold UserScaffold Competent PersonWarehouseWork Zone

TIME 7:00am8:00am9:00am10:00am11:00amNoon1:00pm2:00pm

STUDENT 3
FIRST NAME	LAST NAME
SSN	Or MASC Badge Number
BASIC ORIENTATION Basic Orientation Plus BOP Refresher Has Current BOP Has Current Reciprocal BOP Current BOP certification is a requirement for all sites listed below except GLW.	A BOP certification that has been expired by no more than sixty days is a requirement to take the Basic Orientation Plus Refresher (BOPR) course.

SITE SPECIFIC *ADM Southport requires that a background check (BCG) through LexisNexis be completed for each person before they are eligible to take the ADM site-specific course. **PCS Phosphate at Aurora requires completion of either a background check through DEPS or a current TWIC card. Check here: if a TWIC card will be presented at checkin for classes. ADM* Archer Daniels Midland Southport, NC ALCO Alcoa Charleston, SC BOS Robert S. Bosch Corp. Charleston, SC BPC BP Cooper River, SC BPIC Bushy Park Industrial Complex Charleston, SC DAK DAK Americas North & South Carolina DELL DELL Computers High Point, NC DOW Dow Corning High Point, NC DPTC DuPont Cooper River, SC ELEM Elementis Chromium Wilmington, NC FRTN Fortron Industries Wilmington, NC GLW Corning Glassworks Wilmington, NC HVNS Hovensa Refinery St. Croix, VI KSA KAO Specialties High Point, NC MWV Mead Westvaco Charleston, SC MUHA MUSC Hospital Authority Charleston, SC NVST Invista Wilmington, NC PCS** PCS Phosphate Aurora, NC RHO Rhodia Charleston, SC STOC Stockhausen, Inc. High Point, NC

OTHER COURSES Cold StressConfined Space Attendant/Hole WatchConfined Space EntryElectrical Safety for Non-QualifiedExcavation/TrenchingExcavation/Trenching Competent PersonFall ProtectionFire WatchForkliftHazard CommunicationHazard Materials 24-HourHazard Materials 40-HourHearing ConservationHeat StressHoliday SafetyLock Out/Tag OutOSHA 10-Hour for ConstructionRespiratory ProtectionScaffold UserScaffold Competent PersonWarehouseWork Zone

TIME 7:00am8:00am9:00am10:00am11:00amNoon1:00pm2:00pm

STUDENT 4
FIRST NAME	LAST NAME
SSN	Or MASC Badge Number
BASIC ORIENTATION Basic Orientation Plus BOP Refresher Has Current BOP Has Current Reciprocal BOP Current BOP certification is a requirement for all sites listed below except GLW.	A BOP certification that has been expired by no more than sixty days is a requirement to take the Basic Orientation Plus Refresher (BOPR) course.

SITE SPECIFIC *ADM Southport requires that a background check (BCG) through LexisNexis be completed for each person before they are eligible to take the ADM site-specific course. **PCS Phosphate at Aurora requires completion of either a background check through DEPS or a current TWIC card. Check here: if a TWIC card will be presented at checkin for classes. ADM* Archer Daniels Midland Southport, NC ALCO Alcoa Charleston, SC BOS Robert S. Bosch Corp. Charleston, SC BPC BP Cooper River, SC BPIC Bushy Park Industrial Complex Charleston, SC DAK DAK Americas North & South Carolina DELL DELL Computers High Point, NC DOW Dow Corning High Point, NC DPTC DuPont Cooper River, SC ELEM Elementis Chromium Wilmington, NC FRTN Fortron Industries Wilmington, NC GLW Corning Glassworks Wilmington, NC HVNS Hovensa Refinery St. Croix, VI KSA KAO Specialties High Point, NC MWV Mead Westvaco Charleston, SC MUHA MUSC Hospital Authority Charleston, SC NVST Invista Wilmington, NC PCS** PCS Phosphate Aurora, NC RHO Rhodia Charleston, SC STOC Stockhausen, Inc. High Point, NC

OTHER COURSES Cold StressConfined Space Attendant/Hole WatchConfined Space EntryElectrical Safety for Non-QualifiedExcavation/TrenchingExcavation/Trenching Competent PersonFall ProtectionFire WatchForkliftHazard CommunicationHazard Materials 24-HourHazard Materials 40-HourHearing ConservationHeat StressHoliday SafetyLock Out/Tag OutOSHA 10-Hour for ConstructionRespiratory ProtectionScaffold UserScaffold Competent PersonWarehouseWork Zone

TIME 7:00am8:00am9:00am10:00am11:00amNoon1:00pm2:00pm

SUBMIT REGISTRATIONS