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 Credit Card to Activate Online Account Monthly Invoicing Discounted Training Rates Non-Member Activity Fee $150.00 Annual Non-Member Activity Fee Credit Card to Activate Online Account Monthly Invoicing 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.