Safety Made Simple-Information Form

Customer Information Form
Please provide us with the information we need to customize your Safety Program Manual.

Company Name:	What is the name of your company as you want it to appear on the Safety Program Manual?
Name of the person who will sign the statement of policy:
Title of the person who will sign the statement of policy:
Name of the person who will be the assigned Safety Coordinator:
Office phone number of the Safety Coordinator:
Cell phone number of the Safety Coordinator:
What title do you give to your first level management?
What is your industry? (Be descriptive)
How many employees in your company?

Please list any specific safety rules you want included in your manual; or describe any
particular safety issues you want to address in the safety rules.

Comments (For instance, the source of a personal or business referral)

How did you find out about our business?

Your E-mail address (Required Field):