Please enable JavaScript in your browser to complete this form.Name(s) and Surname(s) *FirstMiddleLastHeight *Please make a selection4' 10" (147 cm)4' 11" (150 cm)5' 0'' (152 cm)5' 1" (155 cm)5' 2" (157.5 cm)5' 3" (160 cm)5' 4" (162.5 cm)5' 5" (165 cm)5' 6" (167.5 cm)5' 7" (170 cm)5' 8" (172.5)5' 9" (175.5)5' 10" (178 cm)5' 11" (180.5 cm)6' 0" (183 cm)6' 1" (185.5 cm)6' 2" (188 cm)6' 3" (190.5 cm)6' 4" (193 cm)6' 5" (195.5 cm)6' 6" (198 cm)6' 7" (200.5 cm)6' 8" (203 cm)Eye Color *Please make a selectionBrown (cafe/marron)Blue (azul)Hazel (avellano)Green (verde)Gray (gris)Date of Birth *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *EmailConfirm EmailCompany Name/Employer Name *Brief description of applicant´s trade and construction work experience *Training Course *Please make a selection8-Hour SST Worker Refresher10-Hour SST Worker40-Hour SST Worker Bundle16-Hour SST Supervisor Refresher32-Hour SST Supervisor62-Hour SST Supervisor Bundle4‐Hour Supported Scaffold User & Refresher8‐Hour Supported Scaffold Installer & Remover Refresher8‐Hour Suspended Scaffold Supervisor Refresher8‐Hour Suspended Scaffold User Refresher16‐Hour Suspended Scaffold User32‐Hour Supported Scaffold Installer & Remover32‐Hour Suspended Scaffold Supervisor40‐Hour Site Safety8‐Hour Site Safety30‐Hour Concrete Safety8‐Hour Concrete Safety Manager Refresher4‐Hour Mast Climber User & Operator8‐Hour Master Rigger Renewal8-Hour Rigging Worker Refresher8‐Hour Special Rigger Renewal16‐Hour Rigger Supervisor Refresher16‐Hour Rigging Worker16‐Hour Special Rigger32‐Hour Rigging Supervisor40‐Hour Hoisting Machine Operator4-Hour Flagger7-Hour Periodic Gas Piping Inspector Qualification16-Hour Limited Gas Work Qualification40-Hour HAZWOPER4-Hour Respirable Crystalline Silica Awareness8-Hour Confined Space Awareness30-Hour OSHA Construction10-Hour OSHA Construction Student Agreement Please sign the form to confirm you have read all policies and procedures. I, the student, fully understands that certificates and licenses will not be released until full payment has been received. I, the student, fully understands that in order to receive a certificate / license card of completion for the course, I must: •Be able to clearly communicate with the instructor and complete all paperwork in the language the course is delivered. •Complete all required paper: course registration, teacher evaluation, course attendance sign-in / sign-out, and any course quizzes, exercises or exams. •Attend all required hours of the course. Any make up sessions must be completed within six months from the course start date. •Class participation during course activities and reviews. •Complete all tests and material with a passing grade of 70% I, the student, give SAFETY PAYS US LLC, permission to verify my information with any regulating city agency that requires these courses for employment, including but not limited to the New York City Department of Buildings, OSHA, as it pertains to state and federal safety laws and regulations, and to any third party through which I have originally registered with, e.g. employer, job-site safety company, job-site general contractor, etc. I, the student, understand that under no circumstance, other than the ones stated specifically in the previous paragraph of this agreement, will SAFETY PAYS US LLC disclose any of my personal information. This includes my personal contact information and payment information, as well as releasing any copies of paperwork pertaining to this course. All certificates / license cards will not be given to any other persons without written consent and permission. I, the student, give SAFETY PAYS US LLC permission to add and keep my contact information through their private database to be notified of class updates and other industry information pertaining to but not limited to safety regulations. I have the right once received emails to choose the option to stop receiving emails at any time. I, the student, understand that a nonrefundable registration fee of $25 is required to secure your spot in the class. This fee will be deducted from the total class price. Please note that if you do not attend the class and fail to provide at least 48 hours notice, the registration fee will be forfeited. I, the student, have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability that is a requirement for any entity registering and providing construction safety training courses. Signature (By signing below, I hereby acknowledge that I have read and fully understand this student agreement. *Clear SignatureSend