Business 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 online account? This person will be responsible for granting authorization of online user account requests for your company. Online user accounts have access to employee training records and have authorization to set up training at the Safety Council.
Administrator Name:*
Administrator Email:*
Administrator Phone:*

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 Monthly Invoicing Not Eligible for Discounted Training Rate
* IMPORTANT * Payment of your membership option is required prior to activating your account. A customer service representative will contact you to obtain credit card information to process this initial, one-time transaction. We do not hold credit card information on file. All other charges will be invoiced to your company on a monthly basis. By signing below, I verify that the information provided is correct and that the above referenced company will remit payment for all charges incurred.
*Name:
*Title:
Access to online registration will not be available until application has been processed and approved by BSC.