2022 Southeastern Ohio Safety Council

SOUTHEASTERN OHIO SAFETY COUNCIL

ENROLLMENT FORM Ohio

Bureau of Workers' Compensation

BWC's Division of Safety & Hygiene co-sponsors safety councils to provide Ohio emplo yers with access to occupational safety and health, workers' compensation and risk management education, networking, and resource sharing.

In completing this enrollment form, the employer makes a commitment to send representatives to monthly safety council meetings.

Enrollment date ---------Employer name __________________________ Ph ysical address _________________________ City ___________State ____ Zip __________ Phone number __________________________ E-mail address __________________________ BWC policy number ________________________ Printed name --------------------------Title ______________________________ Signature ____________________________ Revised May 2022

For more information, please contact

Chris Nourse Southeastern Ohio Safety Council Administrator Phone: (740) 245-7228 Fax : (740) 245-5266 Email: cnourse@rio.edu