SMI Safety Services Application

Cost of Each Progam:
Members: $1,000 per plant, per day (plus expenses).
Nonmembers: $1,250 per plant, per day (plus expenses).
Each program requires about a day to complete and does not interfere with production.

Combine Programs and Save:
The wall-to-wall safety audit can be combined with the in-house training during the same visit for $1,800 (a savings of $200 off the regular price).

Requirements:
Participating companies are responsible for providing a suitable place for training and must have access to a television and VCR.

Company _______________________________________________________________

Address ________________________________________________________________

City __________________ State/Province _________________ Postal Code _________

E-mail _________________________________________________________________

Telephone Fax___________________________________________________________

Person to contact ________________________________________________________

Site of audit/training (if different from above) ____________________________________

Briefly describe operations performed _________________________________________

_______________________________________________________________________

_______________________________________________________________________

Number of employees ________________ Number of shifts _______________________

Plant size (sq. ft.) ____________ Number of buildings _______ Number of floors _______

I understand the SMI Safety Audit and SMI In-House Safety Training are designed to make me aware of potential hazards and possible OSHA violations. They are not a substitute for legal advice, nor do they represent, in any way, a comprehensive study that will meet OSHA inspection standards, nor exempt the company from any OSHA inspections or violations that could be discovered during such an inspection.

Payment by Check: (SMI cannot bill you, please enclose payment.)

I have enclosed check # __________ in the amount of $___________________________

Payment by Credit Card:
Please charge my credit card - Visa MasterCard American Express

Card # ____________________________________ Exp Date _____________________

Card holder's name (please print) ____________________________________________

Card holder's signature (required) ____________________________________________