Professional Safety Training Services, Inc.
102 Browning Lane-Building C- Lower Level Cherry Hill, New Jersey 08003
Phone#: (856) 427-9500 Fax#: (856) 427-9508
Complete the form and mail or fax it to us. Please call with questions.

(All Courses start at 8:30 AM)

STUDENT ENROLLMENT FORM
COMPANY INFORMATION

COMPANY NAME: _______________________________________________________________________

COMPANY ADDRESS: ____________________________________________________________________

CITY: ______________________________STATE: ____________ZIP CODE: _______________________

COMPANY PH.#_________________: COMPANY FAX#:________________ E-MAIL: ___________________

STUDENT INFORMATION

STUDENT NAME: ________________________________________________________________________

STUDENT ADDRESS: _____________________________________________________________________

CITY: STATE: ZIP CODE: _________________________________________________________________

STUDENT PH#:_______________ CELL PH#:______________ E-MAIL:_____________________________

COURSE START DATE: ______________________

NOTE: there are additional courses listed on the Courses web page.

NAME OF COURSE(S) STUDENT WILL ATTEND: (Check all that apply)

___ 40-Hour Hazardous Site Worker       (HAZWOPER)Course
___ 24-Hour Site Support Worker Course
___ 8-Hour Confined Space Entry & Rescue Course
___ 8-Hour Supervisor/Manager Course
___ 8-Hour Annual OSHA HAZWOPER Refresher       Course
___ 8-Hour Supervisor/Manager Course

___ 8-Hour Process Safety Management Course
___ 8-Hour Excavation & Trenching Safety Course
___ 4-Hour Forklift Operator Safety Course
___ 10-Hour Construction Safety Awareness Course
___ 30-Hour Construction Worker Safety Course
___ 4-Hour Bloodborne Pathogens Course


Supervisor’s Name: _________________________________________Title:___________________________

Supervisor’s Signature: ____________________________________Date: ____________________________

PAYMENT INFORMATION

Cardholder’s Name: _________________________________________________________________

Address: __________________________________________________________________________

City: ________________________________________State: ___________Zip:__________________

Phone: ______________________Ext: _____________

Cardholder’s Signature: ______________________________________________________________

Check One:
VISA___ MASTERCARD____AMEX ____CO. CHECK____

CREDIT CARD NUMBER____________________________________ EXPIRATION DATE:___________________

Print This page

Home | Services | Courses | News | Location | Contact | Universal Speakers Bureau | Cal-Tech Learning Center | ECERS | EATS | PSTS Enrollment Form | ECERS Request Form | USB Student Enrollment Form.

© 2002- Professional Safety Training Services, Inc.