C-STOP Registration Form

Date/Time of Class*

MonthDayYear

Initial Classes are given on Mondays Only;

Refresher Classes are given on Tuesday

Please indicate below which plants your company requires you to work in*

Please check one:*

Initial CourseRefresher course

If Refresher Course, List Badge #

Required for Refresher Course. Must bring badge to class.

Additional Course:

Hazwoper Refresher Combo

First Name, Middle Name, Last Name*

Date of Birth*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number: Day*

Evening*

Cell*

Employer Company Name*

Employer Phone Number*

Employer Street Address*

City*

State*

Zip*

Your position with Company*

E-mail*

Company Employee size (required)*

_____________________________________________________________________________________________________

Note: You MUST present a valid form of photo identification before you are allowed to attend C-STOP classes or have your picture made for a badge. “Valid” identification means a U.S. government or state-issued PHOTO I.D. card such as a valid state driver’s license, valid federal/state identification card or current passport. You will present this when you arrive to check in for class.

Arrive for the class at 8:00 a.m. Walk-ins or late arrivals will not be admitted. The class is held at the Center for Workforce Development, 3698 E. Main Rd., El Dorado, AR 71730.

Employees will be asked to sign a consent form upon arrival giving SouthArk authorization to give, share, and discuss your training records, documentation, tests, scores, etc, with your employer or any participating plant sites.

Signature*