Name of Company: ______________________________

Billing Address: _________________________________

City, State: _____________________________________

Telephone #: ___________________________________

Fax #: _________________________________________

Mailing List Names:

1. Name: _______________________________________

Email Address: ________________________________

2. Name: _______________________________________

Email Address: ________________________________

Who with your company would you like to set up as the administrator of the company on-line account? (This person will be responsible for issuing passwords and deleting passwords to your company employees that have access to your company employee records

and have authorization to set up training here at the Safety Council)

Administrator’s Name: ____________________________

There is no charge for member companies, if your company is not a member of CSC of Brazosport there will be a $50.00 set up fee for online account.

Authorized by: __________________________________