Form OSHA-182 Form OSHA-182 Student Data Form

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w:rsidP="00241AE1"><w:pPr><w:spacing w:after="58"/><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t xml:space="preserve">Public reporting burden for this collection of information is voluntary and is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the </w:t></w:r><w:r w:rsidR="003039BC" w:rsidRPr="00CD5241"><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t>Office</w:t></w:r><w:r w:rsidR="0044674E"><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t>of Training</w:t></w:r><w:r w:rsidR="0044674E"><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00C71ADC"><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t xml:space="preserve">Programs and </w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t>Administration,</w:t></w:r><w:r w:rsidR="0044674E"><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t xml:space="preserve"> OSHA </w:t></w:r><w:r w:rsidR="003039BC" w:rsidRPr="00CD5241"><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t>Directorate</w:t></w:r><w:r w:rsidR="0044674E"><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t xml:space="preserve"> of Training and Education, 2020 S. Arlington Heights Road, Arlington Heights, Illinois 60005</w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t>-4102</w:t></w:r><w:r><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t xml:space="preserve">. Persons are not required to respond to the collection of information unless it displays a current valid OMB control number. </w:t></w:r></w:p></w:tc><w:tc><w:tcPr><w:tcW
w:w="1736" w:type="dxa"/><w:tcBorders><w:top w:val="nil"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="nil"/></w:tcBorders></w:tcPr><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:line="120" w:lineRule="exact"/><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:jc w:val="center"/><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t>FORM APPROVED</w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:jc w:val="center"/><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:jc w:val="center"/><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t>OMB NO. 1218-0172</w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:jc w:val="center"/><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451" w:rsidP="00736DFF"><w:pPr><w:spacing w:after="58"/><w:jc w:val="center"/><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t xml:space="preserve">Expires </w:t></w:r><w:r w:rsidR="00736DFF"><w:rPr><w:sz w:val="16"/><w:szCs w:val="16"/></w:rPr><w:t>xx-xx-xxxx</w:t></w:r></w:p></w:tc></w:tr></w:tbl><w:p w:rsidR="00241AE1" w:rsidRDefault="001711E3" w:rsidP="00CD5241"><w:pPr><w:pBdr><w:top w:val="single" w:sz="4" w:space="1" w:color="auto"/><w:bottom w:val="single" w:sz="4" w:space="1" w:color="auto"/></w:pBdr><w:jc w:val="center"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:noProof/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:pict w14:anchorId="13416522"><v:shapetype id="_x0000_t32" coordsize="21600,21600" o:spt="32" o:oned="t" path="m,l21600,21600e" filled="f"><v:path arrowok="t" fillok="f" o:connecttype="none"/><o:lock v:ext="edit" shapetype="t"/></v:shapetype><v:shape id="_x0000_s1053" type="#_x0000_t32" style="position:absolute;left:0;text-align:left;margin-left:270.15pt;margin-top:11.7pt;width:.05pt;height:54.05pt;z-index:251668480;mso-position-horizontal-relative:text;mso-position-vertical-relative:text" o:connectortype="straight" strokeweight="1pt"/></w:pict></w:r><w:r w:rsidR="00241AE1"><w:rPr><w:b/><w:bCs/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>COURSE DATA</w:t></w:r></w:p><w:p w:rsidR="009D7A1D" w:rsidRDefault="009D7A1D"><w:pPr><w:tabs><w:tab w:val="left" w:pos="-1440"/></w:tabs><w:ind w:left="5040" w:hanging="5040"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:tabs><w:tab w:val="left" w:pos="-1440"/></w:tabs><w:ind w:left="5040" w:hanging="5040"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">1. </w:t></w:r><w:r w:rsidR="009D7A1D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>(</w:t></w:r><w:proofErr w:type="gramStart"/><w:r w:rsidR="009D7A1D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>a</w:t></w:r><w:proofErr w:type="gramEnd"/><w:r w:rsidR="009D7A1D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">) </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> Course Number</w:t></w:r><w:r w:rsidR="001A667A"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="009D7A1D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">and </w:t></w:r><w:r w:rsidR="009C2F13"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Title</w:t></w:r><w:r w:rsidR="007357A4" w:rsidRPr="009D7A1D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007357A4" w:rsidRPr="009D7A1D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007357A4" w:rsidRPr="009D7A1D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007357A4" w:rsidRPr="009D7A1D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>2. 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w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>_</w:t></w:r><w:r w:rsidR="00241AE1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">___ / </w:t></w:r><w:r w:rsidR="007C217F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>_</w:t></w:r><w:r w:rsidR="00241AE1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">___ </w:t></w:r><w:r w:rsidR="007C217F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00241AE1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">End Date: </w:t></w:r><w:r w:rsidR="007C217F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>_</w:t></w:r><w:r w:rsidR="00241AE1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">___ / </w:t></w:r><w:r w:rsidR="007C217F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>_</w:t></w:r><w:r w:rsidR="00241AE1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">___ / </w:t></w:r><w:r w:rsidR="007C217F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>_</w:t></w:r><w:r w:rsidR="00241AE1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>___</w:t></w:r></w:p><w:p w:rsidR="007C217F" w:rsidRDefault="001711E3" w:rsidP="007C217F"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:noProof/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:pict w14:anchorId="65CB0470"><v:rect id="_x0000_s1054" style="position:absolute;margin-left:45pt;margin-top:10.05pt;width:535.45pt;height:.95pt;z-index:-251645952;mso-position-horizontal-relative:page" o:allowincell="f" fillcolor="black" stroked="f" strokeweight="0"><v:fill color2="black"/><w10:wrap anchorx="page"/><w10:anchorlock/></v:rect></w:pict></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:line="19" w:lineRule="exact"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451" w:rsidP="00CD5241"><w:pPr><w:pBdr><w:bottom w:val="single" w:sz="8" w:space="1" w:color="auto"/></w:pBdr><w:jc w:val="center"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:b/><w:bCs/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>PERSONAL DATA</w:t></w:r></w:p><w:p w:rsidR="001C028D" w:rsidRDefault="001711E3" w:rsidP="001C028D"><w:pPr><w:tabs><w:tab w:val="left" w:pos="-1440"/></w:tabs><w:ind w:left="10080" w:hanging="10080"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:noProof/></w:rPr><w:pict w14:anchorId="0EED7364"><v:shape id="_x0000_s1055" type="#_x0000_t32" style="position:absolute;left:0;text-align:left;margin-left:269.6pt;margin-top:-.05pt;width:.6pt;height:92.3pt;z-index:251672576" o:connectortype="straight" strokeweight="1pt"/></w:pict></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">3. </w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Student </w:t></w:r><w:r w:rsidR="009C2F13"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Legal </w:t></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Name</w:t></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">4. </w:t></w:r><w:r w:rsidR="005C112C"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>(a)</w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz
w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Job Title</w:t></w:r><w:r w:rsidR="005C112C"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="005C112C"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="005C112C"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r></w:p><w:p w:rsidR="005C112C" w:rsidRDefault="005C112C" w:rsidP="001C028D"><w:pPr><w:tabs><w:tab w:val="left" w:pos="-1440"/></w:tabs><w:ind w:left="10080" w:hanging="10080"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve"> _________________________________</w:t></w:r></w:p><w:p w:rsidR="005C112C" w:rsidRDefault="005C112C" w:rsidP="005C112C"><w:pPr><w:tabs><w:tab w:val="left" w:pos="-1440"/></w:tabs><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>________________________ _____ ___________________________</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r></w:p><w:p w:rsidR="009D7A1D" w:rsidRDefault="009C2F13" w:rsidP="009D7A1D"><w:pPr><w:tabs><w:tab w:val="left" w:pos="5823"/></w:tabs><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:proofErr w:type="gramStart"/><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>First</w:t></w:r><w:r w:rsidR="005C112C"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> M.I.</w:t></w:r><w:proofErr w:type="gramEnd"/><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="005C112C"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Last</w:t></w:r><w:r w:rsidR="005C112C"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> (b) </w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Job Specialization</w:t></w:r></w:p><w:p w:rsidR="005C112C" w:rsidRDefault="009D7A1D" w:rsidP="009D7A1D"><w:pPr><w:tabs><w:tab w:val="left" w:pos="5823"/></w:tabs><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="005C112C"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check11"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="005C112C"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="005C112C"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="005C112C"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00E146D0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> Safety </w:t></w:r><w:r w:rsidR="005C112C"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="005C112C"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check12"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="005C112C"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="005C112C"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="005C112C"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> Health</w:t></w:r><w:r w:rsidR="00E146D0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00E146D0" w:rsidRPr="00187CB1"><w:rPr><w:highlight w:val="yellow"/></w:rPr><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check11"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="00E146D0" w:rsidRPr="00187CB1"><w:rPr><w:highlight w:val="yellow"/></w:rPr><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:rPr><w:highlight w:val="yellow"/></w:rPr></w:r><w:r w:rsidR="001711E3"><w:rPr><w:highlight w:val="yellow"/></w:rPr><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="00E146D0" w:rsidRPr="00187CB1"><w:rPr><w:highlight w:val="yellow"/></w:rPr><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="00E146D0" w:rsidRPr="00187CB1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t xml:space="preserve"> Whistleblower Investigator</w:t></w:r><w:r w:rsidR="00E146D0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="00E146D0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="005C112C"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check13"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="005C112C"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="005C112C"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="005C112C"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> Other________________</w:t></w:r></w:p><w:p w:rsidR="005C112C" w:rsidRDefault="005C112C" w:rsidP="005C112C"><w:pPr><w:pBdr><w:bottom w:val="single" w:sz="8" w:space="1" w:color="auto"/></w:pBdr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="009C2F13" w:rsidRDefault="005C112C" w:rsidP="009C2F13"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>5</w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>. Work Phone</w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>6</w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>. Mobile Phone</w:t></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r></w:p><w:p w:rsidR="009C2F13" w:rsidRDefault="009C2F13" w:rsidP="00CD5241"><w:pPr><w:pBdr><w:bottom w:val="single" w:sz="6" w:space="1" w:color="auto"/></w:pBdr><w:spacing w:line="19" w:lineRule="exact"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00DD1936" w:rsidRDefault="0082395F" w:rsidP="00DD1936"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>7</w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>. Work Email</w:t></w:r></w:p><w:p w:rsidR="006B03B9" w:rsidRDefault="006B03B9" w:rsidP="00DD1936"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="001711E3" w:rsidP="006B03B9"><w:pPr><w:jc w:val="center"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:noProof/></w:rPr><w:pict><v:rect id="_x0000_s1032" style="position:absolute;left:0;text-align:left;margin-left:45pt;margin-top:0;width:535.45pt;height:.95pt;z-index:-251662336;mso-position-horizontal-relative:page;mso-position-vertical-relative:text" o:allowincell="f" fillcolor="black" stroked="f" strokeweight="0"><v:fill color2="black"/><w10:wrap anchorx="page"/><w10:anchorlock/></v:rect></w:pict></w:r><w:r w:rsidR="009C2F13"><w:rPr><w:b/><w:bCs/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>ORGANIZATION</w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:b/><w:bCs/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> DATA</w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451" w:rsidP="006B03B9"><w:pPr><w:pBdr><w:bottom w:val="single" w:sz="8" w:space="1" w:color="auto"/></w:pBdr><w:spacing w:line="19" w:lineRule="exact"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p
w:rsidR="007C6451" w:rsidRDefault="00CD5241"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>8</w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>.</w:t></w:r><w:r w:rsidR="009C2F13"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> Organization Name</w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451" w:rsidP="006B03B9"><w:pPr><w:pBdr><w:bottom w:val="single" w:sz="8" w:space="1" w:color="auto"/></w:pBdr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:line="19" w:lineRule="exact"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="00CD5241"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>9</w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>.</w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Street</w:t></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Address</w:t></w:r><w:r w:rsidR="00DB717F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="00DB717F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="00DB717F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="00DB717F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="00DB717F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="00DB717F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve"> </w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451" w:rsidP="0082395F"><w:pPr><w:pBdr><w:bottom w:val="single" w:sz="6" w:space="1" w:color="auto"/></w:pBdr><w:spacing w:line="19" w:lineRule="exact"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="001711E3"><w:pPr><w:tabs><w:tab w:val="left" w:pos="-1440"/></w:tabs><w:ind w:left="7920" w:hanging="7920"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:noProof/></w:rPr><w:pict w14:anchorId="01773BBA"><v:shape id="_x0000_s1059" type="#_x0000_t32" style="position:absolute;left:0;text-align:left;margin-left:406.4pt;margin-top:0;width:0;height:31.7pt;z-index:251677696" o:connectortype="straight" strokeweight="1pt"/></w:pict></w:r><w:r><w:rPr><w:noProof/></w:rPr><w:pict w14:anchorId="563B0CE9"><v:shape id="_x0000_s1058" type="#_x0000_t32" style="position:absolute;left:0;text-align:left;margin-left:335.65pt;margin-top:0;width:0;height:31.7pt;z-index:251676672" o:connectortype="straight" strokeweight="1pt"/></w:pict></w:r><w:r><w:rPr><w:noProof/></w:rPr><w:pict w14:anchorId="326B2548"><v:shape id="_x0000_s1057" type="#_x0000_t32" style="position:absolute;left:0;text-align:left;margin-left:270.1pt;margin-top:0;width:.05pt;height:31.7pt;z-index:251675648" o:connectortype="straight" strokeweight="1pt"/></w:pict></w:r><w:r><w:rPr><w:noProof/></w:rPr><w:pict w14:anchorId="538209E8"><v:rect id="_x0000_s1056" style="position:absolute;left:0;text-align:left;margin-left:641.5pt;margin-top:332.85pt;width:.95pt;height:33pt;z-index:-251641856;mso-position-horizontal-relative:page;mso-position-vertical-relative:page" o:allowincell="f" fillcolor="black" stroked="f" strokeweight="0"><v:fill color2="black"/><w10:wrap anchorx="page" anchory="page"/><w10:anchorlock/></v:rect></w:pict></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>1</w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>0</w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>.</w:t></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>City</w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>1</w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>1</w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>.</w:t></w:r><w:r w:rsidR="007357A4"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:proofErr w:type="gramStart"/><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>State</w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> 1</w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>2</w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>.</w:t></w:r><w:proofErr w:type="gramEnd"/><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:proofErr w:type="gramStart"/><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>ZIP Code</w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> 1</w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>3</w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>.</w:t></w:r><w:proofErr w:type="gramEnd"/><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00B05C69"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Country</w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="00B05C69"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:line="19" w:lineRule="exact"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="009C2F13" w:rsidP="006B03B9"><w:pPr><w:pBdr><w:bottom w:val="single" w:sz="4" w:space="1" w:color="auto"/></w:pBdr><w:jc w:val="center"/><w:rPr><w:b/><w:bCs/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:b/><w:bCs/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>SUPERVISOR DATA</w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:line="19" w:lineRule="exact"/><w:jc w:val="center"/><w:rPr><w:sz w:val="18"/><w:szCs 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Supervisor Legal Name</w:t></w:r><w:r w:rsidR="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0049248D"><w:rPr><w:sz
w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F" w:rsidRPr="00187CB1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t>1</w:t></w:r><w:r w:rsidR="00CD5241" w:rsidRPr="00187CB1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t>5</w:t></w:r><w:r w:rsidR="0049248D" w:rsidRPr="00187CB1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t xml:space="preserve">. </w:t></w:r><w:r w:rsidR="00E146D0" w:rsidRPr="00187CB1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t xml:space="preserve">Supervisor </w:t></w:r><w:r w:rsidR="00A34EB0" w:rsidRPr="00187CB1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t>Mobile Phone</w:t></w:r></w:p><w:p w:rsidR="0049248D" w:rsidRDefault="0049248D" w:rsidP="0049248D"><w:pPr><w:tabs><w:tab w:val="left" w:pos="-1440"/></w:tabs><w:ind w:left="10080" w:hanging="10080"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r></w:p><w:p w:rsidR="0049248D" w:rsidRDefault="0049248D" w:rsidP="0049248D"><w:pPr><w:tabs><w:tab w:val="left" w:pos="5823"/></w:tabs><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">_______________________ ____ ______________________________ </w:t></w:r></w:p><w:p w:rsidR="0049248D" w:rsidRDefault="0049248D" w:rsidP="0049248D"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:proofErr w:type="gramStart"/><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>First</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve"> M.I.</w:t></w:r><w:proofErr w:type="gramEnd"/><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> Last</w:t></w:r></w:p><w:p w:rsidR="0049248D" w:rsidRDefault="0049248D" w:rsidP="0049248D"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="0049248D" w:rsidRDefault="001711E3" w:rsidP="0049248D"><w:pPr><w:spacing w:line="19" w:lineRule="exact"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:noProof/></w:rPr><w:pict><v:rect id="_x0000_s1050" style="position:absolute;margin-left:45pt;margin-top:0;width:535.45pt;height:.95pt;z-index:-251652096;mso-position-horizontal-relative:page" o:allowincell="f" fillcolor="black" stroked="f" strokeweight="0"><v:fill color2="black"/><w10:wrap anchorx="page"/><w10:anchorlock/></v:rect></w:pict></w:r></w:p><w:p w:rsidR="0049248D" w:rsidRDefault="001711E3" w:rsidP="0049248D"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:noProof/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:pict><v:shape id="_x0000_s1051" type="#_x0000_t32" style="position:absolute;margin-left:270.1pt;margin-top:-.05pt;width:0;height:31.7pt;z-index:251665408" o:connectortype="straight" strokeweight="1pt"/></w:pict></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>1</w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>6</w:t></w:r><w:r w:rsidR="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">. </w:t></w:r><w:r w:rsidR="00E146D0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Work Email</w:t></w:r><w:r w:rsidR="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve">. </w:t></w:r><w:r w:rsidR="0049248D" w:rsidRPr="001C028D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0049248D" w:rsidRPr="001C028D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0049248D" w:rsidRPr="001C028D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0049248D" w:rsidRPr="001C028D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0049248D" w:rsidRPr="001C028D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve"> </w:t></w:r></w:p><w:p w:rsidR="0049248D" w:rsidRDefault="0049248D" w:rsidP="0049248D"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="0049248D" w:rsidRDefault="0049248D" w:rsidP="0049248D"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="0049248D" w:rsidRDefault="0082395F" w:rsidP="009D7A1D"><w:pPr><w:pBdr><w:top w:val="single" w:sz="4" w:space="1" w:color="auto"/><w:bottom w:val="single" w:sz="4" w:space="1" w:color="auto"/></w:pBdr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00187CB1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t>1</w:t></w:r><w:r w:rsidR="00A34EB0" w:rsidRPr="00187CB1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t>7</w:t></w:r><w:r w:rsidR="0049248D" w:rsidRPr="00187CB1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t xml:space="preserve">. </w:t></w:r><w:r w:rsidR="00E146D0" w:rsidRPr="00187CB1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t>Hotel Name and Location</w:t></w:r></w:p><w:p w:rsidR="009D7A1D" w:rsidRDefault="009D7A1D" w:rsidP="009D7A1D"><w:pPr><w:pBdr><w:top w:val="single" w:sz="4" w:space="1" w:color="auto"/><w:bottom w:val="single" w:sz="4" w:space="1" w:color="auto"/></w:pBdr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:ind w:right="-1"/><w:jc w:val="center"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:b/><w:bCs/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>STUDENT GROUP</w:t></w:r></w:p><w:p w:rsidR="00B63ABB" w:rsidRDefault="007C6451"><w:pPr><w:ind w:right="-1"/><w:jc w:val="center"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">(Complete </w:t></w:r><w:r w:rsidR="00FD36A0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">this section by making a single selection from only one of the </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">following </w:t></w:r><w:r w:rsidR="00FD36A0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">group </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>sections #</w:t></w:r><w:r w:rsidR="006A19B2"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>19</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> - #</w:t></w:r><w:r w:rsidR="006A19B2"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>22</w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>)</w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:line="19" w:lineRule="exact"/><w:ind w:right="-1"/><w:jc w:val="center"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:tbl><w:tblPr><w:tblW w:w="0" w:type="auto"/><w:tblInd w:w="120" w:type="dxa"/><w:tblLayout w:type="fixed"/><w:tblCellMar><w:left w:w="120" w:type="dxa"/><w:right w:w="120" w:type="dxa"/></w:tblCellMar><w:tblLook w:val="0000" w:firstRow="0" w:lastRow="0" w:firstColumn="0" w:lastColumn="0" w:noHBand="0" w:noVBand="0"/></w:tblPr><w:tblGrid><w:gridCol w:w="2250"/><w:gridCol w:w="1800"/><w:gridCol w:w="6660"/></w:tblGrid><w:tr w:rsidR="007C6451" w:rsidTr="00FD36A0"><w:trPr><w:trHeight w:val="775"/></w:trPr><w:tc><w:tcPr><w:tcW w:w="2250" w:type="dxa"/><w:vMerge w:val="restart"/><w:tcBorders><w:top w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="nil"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders></w:tcPr><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:line="120" w:lineRule="exact"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00FD36A0" w:rsidRDefault="00FD36A0" w:rsidP="00CD5241"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451" w:rsidP="00A34EB0"><w:r><w:rPr><w:sz
w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>1</w:t></w:r><w:r w:rsidR="00A34EB0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>8</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>. FEDERAL OSHA</w:t></w:r></w:p></w:tc><w:tc><w:tcPr><w:tcW w:w="1800" w:type="dxa"/><w:tcBorders><w:top w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders></w:tcPr><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="00CD5241"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">(a) </w:t></w:r><w:r w:rsidR="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Region</w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:after="58"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p></w:tc><w:tc><w:tcPr><w:tcW w:w="6660" w:type="dxa"/><w:tcBorders><w:top w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders></w:tcPr><w:p w:rsidR="0049248D" w:rsidRDefault="0049248D" w:rsidP="00CD5241"><w:pPr><w:spacing w:before="120"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> 1 </w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">2 </w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">3 </w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">4 </w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">5 </w:t></w:r><w:r w:rsidR="00FD36A0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">6 </w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">7 </w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">8 </w:t></w:r><w:r w:rsidR="0082395F"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>9</w:t></w:r><w:r w:rsidR="00FD36A0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> 10</w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRPr="00280762" w:rsidRDefault="00FD36A0" w:rsidP="00FD36A0"><w:pPr><w:spacing w:after="58"/><w:ind w:left="-120"/><w:rPr><w:sz w:val="20"/><w:szCs w:val="20"/></w:rPr></w:pPr><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="0082395F"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="0082395F"><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="0082395F"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="0082395F"><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="0082395F"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="0082395F"><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="0082395F"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="0082395F"><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="0082395F"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="0082395F"><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="0082395F"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="0082395F"><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="0082395F"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="0082395F"><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="0082395F"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="0082395F"><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="0082395F"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="0082395F"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="0082395F"><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r></w:p></w:tc></w:tr><w:tr w:rsidR="00CD5241" w:rsidTr="00FD36A0"><w:trPr><w:trHeight w:val="53"/></w:trPr><w:tc><w:tcPr><w:tcW w:w="2250" w:type="dxa"/><w:vMerge/><w:tcBorders><w:top w:val="nil"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders></w:tcPr><w:p w:rsidR="00CD5241" w:rsidRDefault="00CD5241"><w:pPr><w:spacing w:after="58"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p></w:tc><w:tc><w:tcPr><w:tcW w:w="1800" w:type="dxa"/><w:tcBorders><w:top w:val="single"
w:sz="7" w:space="0" w:color="000000"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders></w:tcPr><w:p w:rsidR="00CD5241" w:rsidRDefault="00CD5241" w:rsidP="007357A4"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> (b) </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidRPr="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>National</w:t></w:r></w:p><w:p w:rsidR="00CD5241" w:rsidRPr="0049248D" w:rsidRDefault="00CD5241" w:rsidP="00CD5241"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidRPr="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> Office</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r></w:p></w:tc><w:tc><w:tcPr><w:tcW w:w="6660" w:type="dxa"/><w:tcBorders><w:top w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders></w:tcPr><w:p w:rsidR="00CD5241" w:rsidRDefault="00CD5241" w:rsidP="00CD5241"><w:pPr><w:spacing w:before="120"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> DOC DEP DSG DCSP DTSEM DEA DAP </w:t></w:r><w:r w:rsidR="00FD36A0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>D</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>W</w:t></w:r><w:r w:rsidR="00FD36A0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>PP</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00FD36A0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> DTE</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> OTHER</w:t></w:r></w:p><w:p w:rsidR="00CD5241" w:rsidRPr="0049248D" w:rsidRDefault="00CD5241" w:rsidP="00FD36A0"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00FD36A0"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="00FD36A0"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="00FD36A0"><w:fldChar w:fldCharType="end"/></w:r></w:p></w:tc></w:tr><w:tr w:rsidR="0049248D" w:rsidTr="00FD36A0"><w:trPr><w:trHeight w:val="712"/></w:trPr><w:tc><w:tcPr><w:tcW w:w="2250" w:type="dxa"/><w:tcBorders><w:top w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders></w:tcPr><w:p w:rsidR="0049248D" w:rsidRDefault="0049248D"><w:pPr><w:spacing w:line="120" w:lineRule="exact"/></w:pPr></w:p><w:p w:rsidR="0049248D" w:rsidRPr="00B52578" w:rsidRDefault="0049248D" w:rsidP="00A34EB0"><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00A34EB0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>19</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>. STATE OSHA</w:t></w:r><w:r w:rsidR="00A610C1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:br/><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>PROGRAM</w:t></w:r></w:p></w:tc><w:tc><w:tcPr><w:tcW w:w="8460" w:type="dxa"/><w:gridSpan w:val="2"/><w:tcBorders><w:top w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders><w:vAlign w:val="center"/></w:tcPr><w:p w:rsidR="0049248D" w:rsidRDefault="0049248D" w:rsidP="00FD36A0"><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check9"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:bookmarkStart w:id="1" w:name="Check9"/><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:bookmarkEnd w:id="1"/><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">(1) </w:t></w:r><w:r w:rsidR="00FD36A0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Enforcement</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check10"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:bookmarkStart w:id="2" w:name="Check10"/><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:bookmarkEnd w:id="2"/><w:r><w:rPr><w:sz w:val="18"/><w:szCs
w:val="18"/></w:rPr><w:t xml:space="preserve"> (2) Consultation</w:t></w:r></w:p></w:tc></w:tr><w:tr w:rsidR="007C6451" w:rsidTr="00FD36A0"><w:trPr><w:trHeight w:val="595"/></w:trPr><w:tc><w:tcPr><w:tcW w:w="2250" w:type="dxa"/><w:tcBorders><w:top w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders></w:tcPr><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:line="120" w:lineRule="exact"/></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="00CD5241" w:rsidP="00A34EB0"><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>2</w:t></w:r><w:r w:rsidR="00A34EB0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>0</w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>. OTHER</w:t></w:r><w:r w:rsidR="00A610C1"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:br/><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>GOVERNMENT AGENCY</w:t></w:r></w:p></w:tc><w:tc><w:tcPr><w:tcW w:w="8460" w:type="dxa"/><w:gridSpan w:val="2"/><w:tcBorders><w:top w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders><w:vAlign w:val="center"/></w:tcPr><w:p w:rsidR="007C6451" w:rsidRDefault="00737068" w:rsidP="00FD36A0"><w:pPr><w:tabs><w:tab w:val="left" w:pos="-1440"/></w:tabs><w:ind w:left="3600" w:right="-1" w:hanging="3600"/></w:pPr><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check15"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:bookmarkStart w:id="3" w:name="Check15"/><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:bookmarkEnd w:id="3"/><w:r w:rsidR="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> a. Federal</w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check16"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:bookmarkStart w:id="4" w:name="Check16"/><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:bookmarkEnd w:id="4"/><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>b</w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">. </w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>State</w:t></w:r><w:r w:rsidR="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check17"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:bookmarkStart w:id="5" w:name="Check17"/><w:r><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r><w:fldChar w:fldCharType="end"/></w:r><w:bookmarkEnd w:id="5"/><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> c</w:t></w:r><w:r w:rsidR="0049248D"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">. </w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Local </w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00CD5241"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check18"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:r w:rsidR="00CD5241"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="00CD5241"><w:fldChar w:fldCharType="end"/></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> d. </w:t></w:r><w:r w:rsidR="00C4368E"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>International</w:t></w:r></w:p></w:tc></w:tr><w:tr w:rsidR="007C6451" w:rsidTr="00FD36A0"><w:trPr><w:trHeight w:val="928"/></w:trPr><w:tc><w:tcPr><w:tcW w:w="2250" w:type="dxa"/><w:tcBorders><w:top w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders></w:tcPr><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:line="120" w:lineRule="exact"/></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00CD5241" w:rsidRPr="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>2</w:t></w:r><w:r w:rsidR="00A34EB0"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>1</w:t></w:r><w:r w:rsidRPr="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>.</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> PRIVATE</w:t></w:r><w:r w:rsidR="00CD5241"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:br/><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>SECTOR</w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:after="58"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p></w:tc><w:tc><w:tcPr><w:tcW w:w="8460" w:type="dxa"/><w:gridSpan w:val="2"/><w:tcBorders><w:top w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:left w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:bottom w:val="single" w:sz="7" w:space="0" w:color="000000"/><w:right w:val="single" w:sz="7" w:space="0" w:color="000000"/></w:tcBorders></w:tcPr><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:spacing w:line="120" w:lineRule="exact"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:tabs><w:tab w:val="left" w:pos="-1440"/></w:tabs><w:ind w:left="3600" w:right="-1" w:hanging="3600"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00FE789B"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check20"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:bookmarkStart w:id="6" w:name="Check20"/><w:r w:rsidR="00FE789B"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="00FE789B"><w:fldChar w:fldCharType="end"/></w:r><w:bookmarkEnd w:id="6"/><w:r w:rsidR="00CD5241"><w:t xml:space="preserve"> </w:t></w:r><w:proofErr w:type="gramStart"/><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>a. Employer</w:t></w:r><w:proofErr w:type="gramEnd"/><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> Representative</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00FE789B"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check21"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:bookmarkStart w:id="7" w:name="Check21"/><w:r w:rsidR="00FE789B"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="00FE789B"><w:fldChar w:fldCharType="end"/></w:r><w:bookmarkEnd w:id="7"/><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> c. Government Contractor Employee</w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451"><w:pPr><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="00CD5241" w:rsidP="00C4368E"><w:pPr><w:tabs><w:tab w:val="left" w:pos="-1440"/></w:tabs><w:spacing w:after="58"/><w:ind w:left="3600" w:right="-1" w:hanging="3600"/></w:pPr><w:r><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00FE789B"><w:fldChar
w:fldCharType="begin"><w:ffData><w:name w:val="Check22"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:bookmarkStart w:id="8" w:name="Check22"/><w:r w:rsidR="00FE789B"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="00FE789B"><w:fldChar w:fldCharType="end"/></w:r><w:bookmarkEnd w:id="8"/><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> b. Employee Representative</w:t></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00FE789B"><w:fldChar w:fldCharType="begin"><w:ffData><w:name w:val="Check23"/><w:enabled/><w:calcOnExit w:val="0"/><w:checkBox><w:sizeAuto/><w:default w:val="0"/></w:checkBox></w:ffData></w:fldChar></w:r><w:bookmarkStart w:id="9" w:name="Check23"/><w:r w:rsidR="00FE789B"><w:instrText xml:space="preserve"> FORMCHECKBOX </w:instrText></w:r><w:r w:rsidR="001711E3"><w:fldChar w:fldCharType="separate"/></w:r><w:r w:rsidR="00FE789B"><w:fldChar w:fldCharType="end"/></w:r><w:bookmarkEnd w:id="9"/><w:r w:rsidR="007C6451"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> d. </w:t></w:r><w:r w:rsidR="00C4368E"><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>International</w:t></w:r></w:p></w:tc></w:tr></w:tbl><w:p w:rsidR="00BC1A99" w:rsidRDefault="007C6451" w:rsidP="00BC1A99"><w:pPr><w:ind w:right="-1"/><w:jc w:val="center"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/><w:shd w:val="clear" w:color="auto" w:fill="FFFF00"/></w:rPr><w:sectPr w:rsidR="00BC1A99" w:rsidSect="007C6451"><w:pgSz w:w="12240" w:h="15840"/><w:pgMar w:top="360" w:right="631" w:bottom="240" w:left="900" w:header="360" w:footer="240" w:gutter="0"/><w:cols w:space="720"/><w:noEndnote/></w:sectPr></w:pPr><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:lastRenderedPageBreak/><w:t>(Previous editions are obsolete)</w:t></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve">OSHA FORM 182 </w:t></w:r></w:p><w:p w:rsidR="007C6451" w:rsidRDefault="007C6451" w:rsidP="00BC1A99"><w:pPr><w:ind w:right="-1"/><w:jc w:val="center"/><w:rPr><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="003E2195" w:rsidRDefault="00BC1A99" w:rsidP="000110FC"><w:pPr><w:jc w:val="center"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr></w:pPr><w:r w:rsidRPr="003E2195"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:t xml:space="preserve">Instructions for </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:t>State OSHA Training Coordinators, Other Government Agency, and Private Sector Students</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="005C369C"><w:pPr><w:jc w:val="center"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:i/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00A361D8"><w:pPr><w:ind w:left="-120"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:t xml:space="preserve">State OSHA Training Coordinators are required to use this form to register students in Learning Link. Complete the Student Data Form and submit it to the OSHA Training Institute (OT) Student Services at </w:t></w:r><w:hyperlink r:id="rId9" w:history="1"><w:r w:rsidRPr="00062CEA"><w:rPr><w:rStyle w:val="Hyperlink"/><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:t>[email protected]</w:t></w:r></w:hyperlink><w:r><w:rPr><w:rStyle w:val="Hyperlink"/><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:t>.</w:t></w:r><w:r w:rsidR="00CB6683"><w:rPr><w:rStyle w:val="Hyperlink"/><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00CB6683"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:t xml:space="preserve">Other </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:t xml:space="preserve">Government Agency (other than federal and state OSHA) and private sector students requesting enrollment in OTI courses, seminars, etc. must complete the Student Data form and submit it to OTI Student Services at </w:t></w:r><w:hyperlink r:id="rId10" w:history="1"><w:r w:rsidRPr="009F183E"><w:rPr><w:rStyle w:val="Hyperlink"/><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:t>[email protected]</w:t></w:r></w:hyperlink><w:r w:rsidRPr="009F183E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:t>. P</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:t>LEASE NOTE: State OSHA Training Coordinators do not need to complete Items 1 through 3.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00A361D8"><w:pPr><w:ind w:left="-120"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00A361D8" w:rsidRDefault="00BC1A99" w:rsidP="00A361D8"><w:pPr><w:ind w:left="-120"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="19"/><w:szCs w:val="19"/></w:rPr><w:sectPr w:rsidR="00BC1A99" w:rsidRPr="00A361D8" w:rsidSect="00A624F1"><w:headerReference w:type="default" r:id="rId11"/><w:footerReference w:type="default" r:id="rId12"/><w:type w:val="continuous"/><w:pgSz w:w="12240" w:h="15840"/><w:pgMar w:top="360" w:right="631" w:bottom="240" w:left="900" w:header="360" w:footer="240" w:gutter="0"/><w:cols w:space="720"/><w:noEndnote/></w:sectPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00805587" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:ind w:left="540" w:hanging="480"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:lastRenderedPageBreak/><w:t>Item 1</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>a</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Course Number</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t xml:space="preserve"> and </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Title</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:ind w:hanging="480"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t>List the complete course number and full title.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:ind w:hanging="480"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00805587" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:tabs><w:tab w:val="left" w:pos="720"/></w:tabs><w:ind w:left="540" w:hanging="540"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr></w:pPr><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Item </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>1b</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Scheduled Offering ID</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99"
w:rsidP="00074F1F"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve">Enter the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Scheduled Offering ID</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> which can be located in the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>online catalog.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:ind w:hanging="480"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00805587" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:tabs><w:tab w:val="left" w:pos="720"/></w:tabs><w:ind w:left="540" w:hanging="480"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 2</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Course Dates</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:tabs><w:tab w:val="left" w:pos="720"/></w:tabs><w:ind w:left="540" w:hanging="540"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve">Enter the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">start and end dates </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>of the course</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:tabs><w:tab w:val="left" w:pos="720"/></w:tabs><w:ind w:left="540" w:hanging="540"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00805587" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> 3</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Student Legal Name</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Enter the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>student�s legal first name, middle name or initial and last name as it appears on their birth certificate.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00805587" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00805587" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Item </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>4</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>a</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Job Title</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Enter the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>student�s official Job Title.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00805587"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00074F1F" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Item </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>4</w:t></w:r><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>b</w:t></w:r><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Job Specialization</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Place an �x� in the box to indicate the appropriate job specialization</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00074F1F" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00074F1F" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Item 5 </w:t></w:r><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Work Phone</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs
w:val="18"/></w:rPr><w:t xml:space="preserve">Enter the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>student�s work phone number.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00074F1F" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:tabs><w:tab w:val="left" w:pos="0"/></w:tabs><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 6</w:t></w:r><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Mobile Phone</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:tabs><w:tab w:val="left" w:pos="0"/></w:tabs><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve">Enter the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>student�s cell phone number.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:tabs><w:tab w:val="left" w:pos="0"/></w:tabs><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00074F1F" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:tabs><w:tab w:val="left" w:pos="0"/></w:tabs><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 7</w:t></w:r><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Work Email</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00805587" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:tabs><w:tab w:val="left" w:pos="0"/></w:tabs><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve">Enter the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>student�s official work email address.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00074F1F" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:tabs><w:tab w:val="left" w:pos="960"/></w:tabs><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00074F1F" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 8</w:t></w:r><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00074F1F"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Organization Name</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Provide the name of the organization for which the student works</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">. NOTE: State OSHA should type either </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>(</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>state name</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>)</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> Enforcement or </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>(</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>state name</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>)</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> Consultation.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00074F1F"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00B01A2E" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 9</w:t></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>S</w:t></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>treet Address</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Provide the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>street address where student works.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00B01A2E" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr></w:pPr><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 10</w:t></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>City</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Provide the name of the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>city where student works.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book
Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00B01A2E" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 11</w:t></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>State</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Provide the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>state where student works.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00B01A2E" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 12</w:t></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Zip Code</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Provide the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>zip code where student works.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00B01A2E" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr></w:pPr><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 13</w:t></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Country</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00805587" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">For international students, enter the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">country where </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>student works.</w:t></w:r></w:p><w:p w:rsidR="00CB6683" w:rsidRDefault="00CB6683" w:rsidP="00B01A2E"><w:pPr><w:pStyle w:val="ListParagraph"/><w:ind w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00B01A2E" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:pStyle w:val="ListParagraph"/><w:ind w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 14</w:t></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Supervisor Legal Name</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:pStyle w:val="ListParagraph"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Enter the s</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">upervisor�s </w:t></w:r><w:r w:rsidRPr="00B01A2E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>legal first name, middle name or initial and last name as it appears on their birth certificate.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:pStyle w:val="ListParagraph"/><w:ind w:hanging="360"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00A654D4" w:rsidRDefault="00A654D4" w:rsidP="00B01A2E"><w:pPr><w:pStyle w:val="ListParagraph"/><w:ind w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00187CB1" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:pStyle w:val="ListParagraph"/><w:ind w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/><w:u w:val="single"/></w:rPr></w:pPr><w:r w:rsidRPr="00187CB1"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:lastRenderedPageBreak/><w:t>Item 15</w:t></w:r><w:r w:rsidRPr="00187CB1"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:tab/></w:r><w:r w:rsidR="00A34EB0" w:rsidRPr="00187CB1"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/><w:u w:val="single"/></w:rPr><w:t>Supervisor�s Mobile Number</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00187CB1" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:pStyle w:val="ListParagraph"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr></w:pPr><w:r w:rsidRPr="00187CB1"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t xml:space="preserve">Enter the supervisor�s </w:t></w:r><w:r w:rsidR="00A34EB0" w:rsidRPr="00187CB1"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t>mobile number</w:t></w:r><w:r w:rsidRPr="00187CB1"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t>.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00B01A2E"><w:pPr><w:pStyle w:val="ListParagraph"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="009275FA" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:pStyle w:val="ListParagraph"/><w:ind w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs
w:val="18"/></w:rPr><w:t>Item 16</w:t></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t xml:space="preserve">Work </w:t></w:r><w:r w:rsidR="00A34EB0"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Email</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:pStyle w:val="ListParagraph"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Enter the supervisor�s work </w:t></w:r><w:r w:rsidR="00A34EB0"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>email</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:pStyle w:val="ListParagraph"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00187CB1" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:pStyle w:val="ListParagraph"/><w:ind w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr></w:pPr><w:r w:rsidRPr="00187CB1"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t>Item 17</w:t></w:r><w:r w:rsidRPr="00187CB1"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:tab/></w:r><w:r w:rsidR="00A34EB0" w:rsidRPr="00187CB1"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/><w:u w:val="single"/></w:rPr><w:t>Hotel Name and Location</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="00187CB1" w:rsidRDefault="00A34EB0" w:rsidP="009275FA"><w:pPr><w:pStyle w:val="ListParagraph"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr></w:pPr><w:r w:rsidRPr="00187CB1"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t>Enter the name and location of your hotel</w:t></w:r><w:r w:rsidR="00BC1A99" w:rsidRPr="00187CB1"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/><w:highlight w:val="yellow"/></w:rPr><w:t>.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:pStyle w:val="ListParagraph"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="009275FA" w:rsidRDefault="00BC1A99" w:rsidP="000110FC"><w:pPr><w:tabs><w:tab w:val="left" w:pos="5040"/></w:tabs><w:ind w:right="-30"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Items 1</w:t></w:r><w:r w:rsidR="00A654D4"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>8</w:t></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> through 2</w:t></w:r><w:r w:rsidR="00A654D4"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>1</w:t></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">- </w:t></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Student Group</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00BC1A99"><w:pPr><w:ind w:left="720" w:right="-30" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t xml:space="preserve">Select only one student group. </w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="000110FC"><w:pPr><w:tabs><w:tab w:val="left" w:pos="5040"/></w:tabs><w:ind w:right="-30"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="009275FA" w:rsidRDefault="00BC1A99" w:rsidP="00CB6683"><w:pPr><w:tabs><w:tab w:val="left" w:pos="5040"/></w:tabs><w:ind w:left="720" w:right="-30" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Item </w:t></w:r><w:proofErr w:type="gramStart"/><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>1</w:t></w:r><w:r w:rsidR="00A654D4"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>8</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidR="00CB6683"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidRPr="009F183E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Federal</w:t></w:r><w:proofErr w:type="gramEnd"/><w:r w:rsidRPr="009F183E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t xml:space="preserve"> OSHA</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="00CB6683"><w:pPr><w:ind w:left="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">If student works for federal OSHA, </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>place an �x� in the box for the appropriate OSHA Region or National Office Directorates.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:ind w:left="630"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="009275FA" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">Item </w:t></w:r><w:r w:rsidR="00A654D4"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>19</w:t></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="009F183E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>State OSHA Program</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/><w:t>I</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">f student works for a state OSHA program, </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">place an �x� in the box for the </w:t></w:r><w:r
w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>appropriate program</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>, eith</w:t></w:r><w:r w:rsidR="00CB6683"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>er</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Enforcement or Consultation</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="009275FA" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 2</w:t></w:r><w:r w:rsidR="00A654D4"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>0</w:t></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="009F183E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Other Government Agency</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">If student works for </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">another </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>governm</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">ent agency, place an �x� in the </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>appropriate</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> box for either </w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Federal, State, Local, or International</w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> agency</w:t></w:r><w:r w:rsidRPr="00805587"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>.</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="009275FA" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="009275FA" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>Item 2</w:t></w:r><w:r w:rsidR="00A654D4"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>1</w:t></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="009F183E"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:b/><w:sz w:val="18"/><w:szCs w:val="18"/><w:u w:val="single"/></w:rPr><w:t>Private Sector</w:t></w:r></w:p><w:p w:rsidR="00BC1A99" w:rsidRPr="009275FA" w:rsidRDefault="00BC1A99" w:rsidP="009275FA"><w:pPr><w:ind w:left="720" w:hanging="720"/><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr></w:pPr><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:tab/></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">If student works for </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">the </w:t></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">private sector, </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">place an �x� in the </w:t></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve">appropriate </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t>box for Employer</w:t></w:r><w:r w:rsidRPr="009275FA"><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz w:val="18"/><w:szCs w:val="18"/></w:rPr><w:t xml:space="preserve"> </w:t></w:r><w:r><w:rPr><w:rFonts w:ascii="Book Antiqua" w:hAnsi="Book Antiqua"/><w:sz 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