Application for Qualification, Course, Or Examination

Application for Qualification, Course, or Examination

Course or Qualification:______

Check one: ___ Trainee has not been previously registered for a CTQP course (attach a Trainee Personal Data Sheet)

___ Change in trainee personal information (attach a Trainee Personal Data Sheet)

___ Trainee information has not changed since the last class or exam

APPLICANT INFORMATION:

First Name: ______MI: ______Last Name: ______

FL Driver’s License #: ______Work Location (City): ______

Employer: ______

TRAINING CONTACT INFORMATION (Person responsible for scheduling trainees for CTQP courses):

Contact Person: ______Fax #: ______

FL Driver’s License #: ______Email: ______

PAYMENT INFORMATION

(Person/Organization responsible for payment of fee for this class):

Name of individual or organization: ______

Billing Address: ______

City, State, Zip: ______

Phone: ______

Florida Vendor ID # or FEID #: ______

Course Title / Preferred / Alternate 1 / Alternate 2
Date: / Date: / Date:
Location: / Location: / Location:
Part A / Application for Qualification as: ______ / By signing 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 signing this 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.
Signature of Applicant
Date Signed
Application Submitted By
Signature
This application is for (check one):
Initial Qualification / ___ / $ ______
Requalification / ___ / $ ______
Not applying for qualification / ___ / $ _ 0______
Qualification or Requalification fee previously paid / ___ / $ _ 0______
Fee Total for Part A / $ ______
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
______/ ______/ ______/ ______
______/ ______/ ______/ ______
Part B / Application for Course Only, Course and Exam(s), or Exams:
Course and all required exam(s) / ___ / $ ______
Written Exam (____Challenge or ____Reexam) / ___ / $ ______
Proficiency Exam / ___ / $ ______
Course Only / ___ / $ ______
Fee Total for Part B / $ ______
Total Fee (Part A + Part B) / $ ______