Form 700-010-51 "Provider Request for Fdot's Construction Training Qualification Program" - Florida

What Is Form 700-010-51?

This is a legal form that was released by the Florida Department of Transportation - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2017;
  • The latest edition provided by the Florida Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 700-010-51 by clicking the link below or browse more documents and templates provided by the Florida Department of Transportation.

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Download Form 700-010-51 "Provider Request for Fdot's Construction Training Qualification Program" - Florida

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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
700-010-51
CONSTRUCTION
PROVIDER REQUEST
12/17
FOR FDOT’S CONSTRUCTION TRAINING QUALIFICATION
PROGRAM
Submit To: FDOT State Construction Training Administrator
605 Suwannee St., Mail station 31
Tallahassee, Florida 32399-0450
Or email to:
Susan.Robeson@dot.state.fl.us
Initial Provider Request
Request for Additions
Provider No.:
Request for Changes
Provider No.:
(Check only one box per submitted request form)
contact details to post on website:
Entity Name:
Entity name:
Address:
Contact Person:
Address:
Email address:
Phone number:
Phone number:
Entity Type:
Email address:
(see CTQM 1.10(2) for details)
Website:
Seeking Approval as (or additions or changes to) a CTQP Provider for the following course:
(Each course desired will require a separate Provider Approval Request form to be submitted)
Instructors’ names and TIN Numbers of the CTQP Approved Instructors for this course:
Name:
TIN:
Name:
TIN:
Name:
TIN:
Physical address of classroom facilities:
(see CTQM 1.10(2) for details)
(Each additional location will require an additional Provider Approval Request form to be submitted.)
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
700-010-51
CONSTRUCTION
PROVIDER REQUEST
12/17
FOR FDOT’S CONSTRUCTION TRAINING QUALIFICATION
PROGRAM
Submit To: FDOT State Construction Training Administrator
605 Suwannee St., Mail station 31
Tallahassee, Florida 32399-0450
Or email to:
Susan.Robeson@dot.state.fl.us
Initial Provider Request
Request for Additions
Provider No.:
Request for Changes
Provider No.:
(Check only one box per submitted request form)
contact details to post on website:
Entity Name:
Entity name:
Address:
Contact Person:
Address:
Email address:
Phone number:
Phone number:
Entity Type:
Email address:
(see CTQM 1.10(2) for details)
Website:
Seeking Approval as (or additions or changes to) a CTQP Provider for the following course:
(Each course desired will require a separate Provider Approval Request form to be submitted)
Instructors’ names and TIN Numbers of the CTQP Approved Instructors for this course:
Name:
TIN:
Name:
TIN:
Name:
TIN:
Physical address of classroom facilities:
(see CTQM 1.10(2) for details)
(Each additional location will require an additional Provider Approval Request form to be submitted.)
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
700-010-51
CONSTRUCTION
PROVIDER REQUEST
01/16
FOR FDOT’S CONSTRUCTION TRAINING QUALIFICATION
PROGRAM
Check the boxes for the corresponding documentation submitted with this request
Attached are photographs (jpeg file format) of the classroom set up at the above listed location.
These photos will be evaluated to determine if the facility meets the classroom
requirements as outlined in CTQM 1.10.1(6).
Attached are photographs (jpeg file format) of the audio visual equipment.
These photos will be evaluated to determine if the equipment meets the requirements as
outlined in CTQM 1.10.2(7).
Attached are photographs (jpeg file format) of any technical equipment the prospective Provider intend to use to
present the CTQP course listed above.
These photos will be evaluated to determine if the technical equipment meets the
requirements as outlined in CTQM 1.10.1(8).
As a condition of Provider approval, the above listed entity agrees that if approved by the Department as a CTQP
Training Provider they will abide by and be bound by the requirements of the Departments’ CTQM and any
updates thereto. This entity further agrees that if it ceases to be or will cease to be an approved Provider for any
reason then the entity will forward to the Department (at the submit to address shown above) all the entity’s CTQP
training records which are required by the Departments CTQM and for which the retention period is not yet
expired.
I agree to be bound by and to comply with any conditions set forth by the State Construction Training
Administrator (SCTA) and any conditions set forth in the CTQM. I agree that if my performance as a Provider is
called into question for any reason the SCTA may upon written notice to my company, suspend my approval as a
Provider for CTQP courses and examinations.
____________________________________________________
Signature of entity’s principal officer (see CTQM 1 for details)
Date
Print Name
Signatory’s Title
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