Account Application

Name of Company:*
Billing Address:*
City:*
State:*
Zip: *
Phone:*
Fax:
Designated Contacts:
1. Name:*
Email:*
2. Name:
Email:
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/modifying passwords for your company employees that have access to your employee training records and have authorization to set up training at the Safety Council.)
Administrator Name:*
Select Account Type:
	Membership & Online Account $300.00 Annual Membership Fee Online Account Monthly Invoicing Discounted Training Rates Non-Member Activity Fee $150.00 Annual Non-Member Activity Fee Online Account Requires Credit Card on File for 6 Months Not Eligible for Discounted Training Rate
By completing the Name and Title fields below, I certify that all information I have provided is correct to the best of my knowledge. It is agreed that the above company will submit payment for all charges incurred.
*Name:
*Title:
Access to online registration will not be available until application has been processed and approved by CSC and User ID, Password, and Account Number have been issued.