Worker Protection Standards

Welcome to the "Worker Protection Standard: Train the Trainer" course.
• On this page we require you fill in all of the fields below.
• On the next page, you will complete a short pre-course survey.
• Once you submit your answers, you will be given an enrollment key which provides you access to the online course. (Complete directions provided once you submit your answers.)

1. Enter today's date

	MM		DD		YYYY
Today's date is	Enter today's date Today's date is Month	/	Day	/	Year

2. Your First Name

Your First Name

3. Your Last Name

Your Last Name

4. Business Name

Business Name

5. Business Address

Business Address Street Address
Mailing Address (if different than Street Address)

6. Business City/Town

Business City/Town

7. Business State

Business State

8. Business Zip Code

Business Zip Code

9. Business Phone Number including area code
(example format: 515-555-1234)

Business Phone Number including area code (example format: 515-555-1234)

10. Email address

Email address

11. Approximate Number of People to be Trained at Your Business

Approximate Number of People to be Trained at Your Business

12. I Am ...(check all that apply)...

I Am ...(check all that apply)... Employer

Supervisor

Certified Pesticide Applicator

Other

13. Are there any additional comments you wish to provide?

Are there any additional comments you wish to provide?