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