Northwest Michigan Industrial Association - Safety Performance Award Contest

We wish to participate in the Association's Safety Contest and I certify that the information given is accurate to the best of my knowledge.

Full Name: * Date of Birth: *

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NWMIA 2004 Safety Performance Award Contest Form
* indicates required fields
Company Name:	*
Mailing Address:	*
Street Address:	*
City:	*** State: * Zip Code: ***
Phone:	*
Fax:

2005 DATA: (January 1, 2005 through December 31, 2005)
Total number of injury & illness cases reported on 2004 MIOSHA log:	*
Total number of lost time days reported in 2004 MIOSHA log:	*
Total number of restricted days reported on 2004 MIOSHA log:	*
Total 2004 hours worked (combined hourly & salary):	*
2006 DATA: (January 1, 2006 through December 31, 2006)
Total number of injury & illness cases reported on 2004 MIOSHA log:	*
Total number of lost time days reported in 2004 MIOSHA log:l	*
Total number of restricted days reported on 2004 MIOSHA log:	*
Total 2004 hours worked (combined hourly & salary):	*

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