Safety Council of East Texas

Membership Application

Date

Company Name

Facility Mailing

City

State

Zip Code

Telephone #

Fax #

# Employees

Contact Persons (Please list in priority of contact order)

Name	Title	Phone

Please give a brief description of your company's business activities

Please indicate below the types of training your company is interested in (Priority 1 through 5)

Hazard Communication Hazwoper (40Hr) Hazwoper (24Hr) Hazwoper (8Hr) Accident Investigation Electrical Safety Substance Abuse Lockout/Tagout Hazard Recognition	Confined Space Fire Prevention/Extinguisher H2S Training Defensive Driving Fit Testing Scaffold Training Ladder Safety Aerial Lift Forklift Training	Respiratory Protection Medic First Aid/CPR Shoring and Excavation Hearing Conservation OSHA Outreach (30Hr) OSHA Outreach (10Hr) Bloodborne Pathogens Asbestos Training PPE
Basis Plus Orientation Site Specifics Other

Please list names of Company Representatives willing to participate in Committee activities

Name	Phone

Membership / Payment

I have enclosed a check for $300.00 (Regular Annual Membership)

Please make check payable to:

                                  Safety Council of East Texas, Inc.
                                  440 North Eastman Road, Suite B
                                  Longview, Texas 75601-6901