2022 Safety Awards Program Entry Form for Manufacturers and Contractors

Instructions

Entries for the NCMA/ICPI Safety Awards program must be received no later than March 31, 2023. Multiple facilities/locations may be listed on this form for ease of entry. If additional entries are needed, please fill in the available fields below and submit; then fill out an additional entry form. All information required in the form below should be taken from the OSHA 300A logs (or Canadian equivalent) for the 2022 calendar year. There is NO ENTRY FEE and no need to submit additional documentation at this time other than this form. Fees will be charged only for those companies wishing to receive an award plaque for those award(s) for which they are eligible. The Safety Representative listed on this form will be notified by April 20, 2023, of awards won with the option to purchase physical awards/plaques. Confirmation of plaque(s) purchase must be received no later than May 12, 2023. Program guidelines are available on our website (www.ncma.org). If you have any questions in the submission process, please contact James Trednick at jtrednick@ncma.org or 703-713-1900.

Question Title

* 1. Company Information:

Name of Safety Representative *

Name of Company *

Safety Representative Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Safety Representative Email Address *

Safety Representative Phone Number *

Question Title

* 2. What type of member are you?

Manufacturer

Contractor