Safety Foundations Certificate Request Form – General Industry
• Requires 4 OSHA courses - A minimum of 3 courses must have been taken with Chabot-Las Positas
Community College District – OSHA Training Institute Education Center.
• Only OSHA numbered courses taken at an OSHA Training Institute Education Center will be accepted;
online courses for the OSHA 30-hour requirement taken through an authorized provider will be accepted.
• Copies of certificates must be provided with request; please do not submit until all courses are complete.
• Applicant is responsible for tracking their completion progress and submitting this application form when
all requirements have been met.
• All courses applied towards certificates must have been taken within the previous 5 years.
Name: Date Requested:
Street Address:
City: State: Zip:
Phone Number: Email:
Payment Information:
Payment information must be included to complete the registration process. Certificate fee is $99.00.
Enclosed is a check payable to Chabot-Las Positas Community College District – OSHA Training
Institute Education Center
Please charge the credit card provided below (you may also call our office at (866) 936-6742 to make
credit card payment)
Credit
Card Number Name on Credit Card Exp. Date
Bill
ing Address City State Zip Code
Signat
ure of Credit Card Holder Date Card Type
(Visa/MasterCard/AMEX accept
ed)
Completed registration forms and payment can be submitted by:
Email: otc@clpccd.org
Fax: (925) 460-0133
Mail: 5860 Owens Dr, 3
rd
Floor, Pleasanton, CA 94588
OSHA4you.com (866) 936-OSHA (6742) otc@clpccd.org
Required Courses:
OSHA 30-hour for General Industry (OTC 110)
OSHA 7105: Evacuation and Emergency Planning
OSHA 7505: Introduction to Incident (Accident) Investigation
OSHA 7845: Recordkeeping Rule Seminar
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