Williams Earth Sciences - FDOTC/CTQP Training Classes - Secure Server Registration - New Student

ONLINE REGISTRATION FORM
NEW STUDENT / RETURNING STUDENT WITH REGISTRATION CHANGES (FDOT EMPLOYEE)

This form is to be completed by FDOT Employees Only who have not been previously registered for a CTQP course or who’s personal information has changed since the last class or exam.

APPLICANT INFORMATION
(all fields required except as noted below)

Check One	New Applicant	Change of Information

First Name
Middle Initial
Last Name
Title
Home Address
City
State
Zip
Home Phone
Work Phone
Work Fax
FL Driver's License#
E-mail

FLORIDA DEPT of TRANSPORTATION EMPLOYMENT INFORMATION

FDOT District
FDOT Work Address
City
State
Zip
Supervisor Name
Supervisor Phone
Supervisor Fax
Supervisor Email

FDOT TRAINING CONTACT INFORMATION

This area to be completed only by those responsible for scheduling trainees for CTQP courses. If you have not been designated as a Training Contact for your employer, please do not complete this area.

Training / Unit Coordinator
Cost Center
District
Suncom Phone Number	Ext
Email (@dot.state.fl.us)

QUALIFICATION

I verify that I have met all training course prerequisites...	Yes	No
I am seeking CTQP Qualification.
I verify that I have met all qualification work experience requirements...		Yes	No	N/A
Enter comments below...

COURSE SELECTION & FEES

Step 1 - choose the classes you would like to attend

Step 2 - choose your preferred date or location

Step 3 - check the box with applicable course fee

PAYMENT INFORMATION

Credit Card (MasterCard, Visa, or American Express)
Card Number
Expiration Date
Cardholder's Name (as it appears on card)
For your security, we ask for the 3 or 4 digit Account Verification Code located on the back of your card or on American Express on the front.
Account Verification Code
Cardholder Email
Cardholder Billing Address
Cardholder Billing City
Cardholder Billing State
Cardholder Billing ZIP

NOTE - The first time you apply for a DOT Training Course or examination you will need to show proof of identification with a Florida Driver License or Florida Identification Card. When you are issued a DOT Construction Training Examination, you will be asked to show your Florida Driver License or Florida ID Card. If you fail to show your Florida License or Florida ID Card or if your license/card is unreadable, altered, or tampered with, you may not be allowed to take a DOT Construction Training Examination.

By submitting this application, I agree that all information is truthful. I understand the procedure for obtaining Qualification is described in the FDOT Construction Training and Qualification Manual and I will abide by the terms in the manual. I understand that any submittal of false information on this application or any future documentation submitted while in training or under qualification shall subject my DOT qualification to review and possible suspension or revocation.

All information you provide is submitted via our Secure Server
using the latest in SSL 128 bit data encryption technology.

Revised: March 11, 2007