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

ONLINE REGISTRATION FORM
RETURNING STUDENT (Non-FDOT Employee)

This form is to be completed by returning students who have previously registered for a CTQP course and who's registration information has not changed since the last class or exam.

APPLICANT INFORMATION

First Name
Middle Initial
Last Name
FL Driver's License #
E-mail

EMPLOYMENT INFORMATION

Employer
Work Location (City)

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.

Contact Person
Fax Number
Contact Phone #
Email

QUALIFICATION

Application for Qualification as
This application is for (check one)	Initial Qualification Re-Qualification

NOTE - Additional documentation or certificates may be required for certain qualifications. Refer to Construction Training and Qualification Manual for exact requirements. Qualification cannot be issued without required documentation.
Certificate Designation	Issue Date	Expiration Date	Certificate Number

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, and 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

By submitting this application, I agree that all information is truthful and I confirm I have met the minimum work experience and training course prerequisites required for the above listed qualification, if applicable. I understand any incorrect information on this form could cause my application to be delayed or rejected. If information contained in this form is discovered to be blatantly false, this could lead to revocation of FDOT issued qualifications. By submitting this online form, I understand the procedure for obtaining qualification is described in the FDOT Construction Training manual and will abide by the terms contained in the manual.

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

Revised: May 07, 2007