Ross County Safety Council enrollment form

Chillicothe Ross Chamber of Commerce

Safety Council
Enrollment form

www.chillicotheohio.com

Mission statement: The Chillicothe Ross Chamber of Commerce promotes economic and community development by providing services and addressing issues important to business.

Becoming a member of the council is easy. Just complete all of the information below and click once on the submit button. We'll be in touch with you shortly. To be eligible for the next discount rebate program of the Ohio Bureau of Workers' Compensation, you must be enrolled by July 31, 2007. To maintain membership in the council, your company must be represented at a majority of the council's functions, such as the monthly luncheons and the awards banquet, and you must submit both semi-annual injury reports (which determine your eligibility for awards). Information for the forms comes straight from your OSHA logs. If you have any questions or problems with this form, give the chamber a call at 702-2722 and ask for Rosie.

Please provide all of the following information:

Name

Title

Organization

Street Address

Address (cont.)

City

Zip Code

Work Phone

Fax

E-mail

Average number of employees:

Type of work

Your BWC policy number (please double-check as this could affect your potential rebate)

The exact name as it appears on the BWC certificate

(please double-check as this could affect your potential rebate)