DEPARTMENT OF LABOR & INDUSTRY BUREAU OF OCCUPATIONAL & INDUSTRIAL SAFETY FOR L&I USE ONLY Accr.#: Date: LEAD TRAINING COURSE NOTIFICATION FORM002 PLEASE TYPE OR PRINT NEATLY IN INK002 5 days prior to the start of the course (Monday-Saturday); 002revisions must be sent as soon as the change is decided; cancellations must be sent no later than the start date of the course. Can be mailed, faxed to 717-705-0196, or emailed to CALBOIS@pa.gov.002 Type of INITIAL REVISION (Fill in or cross out any sections that need revising.) CANCELLATION Deadline If no, provide explanation: Training Training Provider Provider Information Accreditation # Contact Person Telephone Course Date(s) of Course Information (Training Type of Course: course date Worker Worker Refresher cannot exceed Supervisor Supervisor Refresher the course accreditation222s expiration date)Inspector Inspector Refresher Risk Assessor Risk Assessor Refresher Project Designer Project Designer Refresher Location Lecture Information Date(s) Street Address and RCity, State, and Zip Code County Telephone Hands-On (Initial courses only) Date(s) Street Address and RCity, State, and Zip Code County Telephone 002003002003Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002LIBI-605L REV 10-18 (Page 1 of 1) American LegalNet, Inc. www.FormsWorkFlow.com