CSMC Student Information Form

Name as you would like it to appear on your certificate:(Required)
Name as you would like it to appear on your name tag:(Required)
Address(Required)
MM slash DD slash YYYY
Employer Address(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Are you a US Veteran?(Required)

Please prioritize the following five safety topics in the order of your interest in learning more about them. (1 would be your first choice, 2 your second choice...)

Three safety topics I most want to learn about:(Required)
Select 3 of the above options
Three safety topics I am already somewhat familiar with:(Required)
Select 3 of the above options
This field is for validation purposes and should be left unchanged.

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