Date: [Month Day, Year]
Please read through each section carefully and fill in all required information accurately. Upon completion, this form should be signed by the instructor/supervisor and the employee.
Full Name: | [Name] |
---|---|
Department: | |
Email Address: | |
Phone Number: |
Model: | Lift Assist Pro 3000 |
---|---|
Serial Number: | |
Type of Equipment: |
Certification Date: | [Month Day, Year] |
---|---|
Supervisor Name: | |
Validity Period: |
Date: | [Month Day, Year] |
---|---|
Theory Test Score: | |
Practical Test Score: | |
Observations: | |
Certification Status: |
Supervisor Signature:
[Your Name]
[Job Title]
[Month Day, Year]
I acknowledge that I have been trained and tested on the operation of the equipment listed above and understand the safety protocols and operational procedures. I understand that my certification is subject to periodic review and can be revoked if I fail to adhere to the established safety standards and operational guidelines.
Employee Signature:
[Name]
[Job Title]
[Month Day, Year]
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