Common Company Name:

Designated Company Safety Officer:

Address:

City:      State:      Zipcode:

Telephone Number:     Fax:

Company Website:

General Contractor    Subcontractor

Does this company hire subcontractors?  Yes     No

What nature work do subcontractors provide?

Average Number of Employees:

Nature of Work Performed by Employees:

Commercial Construction      Residential Construction

Equipment Owned or Rented Frequently by the Company.  Please include Brands and Models:

Check tasks performed or equipment operated by this company:

Do your employees erect or work from scaffolding?

Do you dig or work from trenches or excavations?

Are your employees required to enter confined spaces?

          Please List:

Do your employees operate forklifts?

     Aerial Work Platforms: 

Scissor Lifts?     Boom Lifts?

     Do your employees use:

Ladders?     Welding or cutting equipment?     Powered Actuated Tools?

Do your employees work on jobsites that exceed 5 miles from medical care?

Do your jobsites have office trailers located on-site?

Contact:      Phone:

Best Time to contact:

Email:

* A consultant will promptly contact you for a brief interview prior to preparing your program material. Payment arrangements will be made at that time.