Clone of Fixed Telehandler March 27-28

1

Submission Type:* This field is required.

I am submitting this application for myself.

I am submitting this application on behalf of the candidate.

2

CCO Candidate ID #:* This field is required.If you do not have a CCO Candidate ID #, you must first register for one at my.ccocert.org in order to submit this application. We specialize solely in CCO certification and must have this number in order to register you for any testing. It is a 9-digit number that will begin with either 444 or 555.

3

Candidate Date of Birth:* This field is required.

4

Candidate Name:* This field is required.

First Name

Middle Initial

Last Name

Suffix

5

Today's Date:* This field is required.

6

Candidate Mailing Address:* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

7

Candidate Phone Number:* This field is required.

8

Candidate Email Address:* This field is required.

example@example.com

Confirm Email

9

Candidate's Employer Name:* This field is required.(Please put N/A if not applicable or if you do not wish to provide.)

10

Candidate's Employer Address:* This field is required.(Please put N/A if not applicable or if you do not wish to provide.)

Street Address

Street Address Line 2

City

State

Zip Code

Country

11

Candidate's Supervisor/Manager Name:* This field is required.(Please put N/A if not applicable or if you do not wish to provide.)

12

Candidate's Supervisor/Manager Phone Number:* This field is required.(Please put all zeroes if not applicable or if you do not wish to provide.)

13

Candidate's Supervisor/Manager Email Address:* This field is required.(Please put N/A if not applicable or if you do not wish to provide.)

example@example.com

14

Is this for a new certification or recertification? (Must currently hold a valid certification to qualify for recertification. Renewing an expired certification is not considered recertifying. If expired, select "new certification.")* This field is required.

New Certification

Recertification

15

Operator Experience Requirement (Recertification Candidates Only)* This field is required.Do you have 1,000 hours of documented related experience during your current certification period?

Yes, and I understand that CCO may, at any time, request documentation to be provided in order to verify my experience, and if such documentation is not provided, my certification may be impacted.

No, and I understand I must take and pass any applicable practical exam(s) prior to my expiration date.

16

What type of training and/or testing are you applying for?* This field is required.

Full Training Course - Includes classroom preparation for the written exam and hands-on training for the practical exam as well as written and practical testing.

Written Exam Only - With Classroom Preparation

Practical Exam Only - With Practice Time

Written Exam Only - No Classroom Preparation

Practical Exam Only - No Practice Time

Written and Practical Exams Only - No Classroom Preparation or Practice Time

17

What type of training and/or testing are you applying for?* This field is required.

Practical Exam - With Practice Time

Practical Exam Only - No Practice Time

18

Candidate Attestation:* This field is required.I declare that the information contained in this application/attestation, as well as the information in any required accompanying documentation, is true and correct. I understand and agree that my failure to provide accurate and complete information or abide by CCO’s policies and procedures may constitute sufficient grounds for the rejection of my application, or denial or revocation of my certification, or other sanctions. I understand that CCO reserves the right to verify any information in this submittal or in connection with any applicant’s certification or other credential. I expressly consent to CCO’s release of information consistent with CCO’s Information Release Policy, and expressly consent to CCO's Privacy Policy as set forth on the CCO website, as well as CCO's Financial Terms and Conditions and the Trademark Usage Policy, as they may be amended from time to time. I also agree to be bound by CCO’s Program Participant Agreement, and further agree that any dispute relating to this document shall be commenced in the State of Utah. If I am submitting an application on the applicant’s behalf, I confirm that I have been expressly authorized by the applicant to submit the application, subject to the accompanying attestation, on his/her behalf.

I have read and understood the above attestation statement.

19

Name of the Person Filling Out This Form:* This field is required.

First Name

Middle Initial

Last Name

Suffix

20

Signature of the Person Filling Out This Form:* This field is required.

Clear