City: Phone: State: Fax: Zip Code: Email: Company President/CEO Name: President/CEO Signature: Safety Director Name: Safety Director Signature: PLEASE NOTE: Written or electronic signatures must be provided for application to be processed. Section 2: Entry Category and injury illness data & rates BUILDING DIVISION Under 200,000 work hours 200,001 – 500,000 work hours 500,001 – 1 million work hours Over 1 million work hours HEAVY/CIVIL/HIGHWAY DIVISION Under 200,000 work hours 200,001 – 500,000 work hours 500,001 – 1 million work hours Over 1 million work hours SPECIALTY DIVISION Under 500,000 work hours 500,001 – 1 million work hours Over 1 million work hours Calendar Calendar Calendar Year Year Year (YTD) 2011 2012 July 2013 1. Average Number of Employees 2. % of Self-Performed Hours Worked 3. Total Employee-Hours Worked
City: Phone: State: Fax: Zip Code: Email: Company President/CEO Name: President/CEO Signature: Safety Director Name: Safety Director Signature: PLEASE NOTE: Written or electronic signatures must be provided for application to be processed. Section 2: Entry Category and injury illness data & rates BUILDING DIVISION Under 200,000 work hours 200,001 – 500,000 work hours 500,001 – 1 million work hours Over 1 million work hours HEAVY/CIVIL/HIGHWAY DIVISION Under 200,000 work hours 200,001 – 500,000 work hours 500,001 – 1 million work hours Over 1 million work hours SPECIALTY DIVISION Under 500,000 work hours 500,001 – 1 million work hours Over 1 million work hours Calendar Year 2011 Calendar Year 2012 Calendar Year (YTD) July 2013 1. Average Number of Employees 2. % of Self-Performed Hours Worked 3. Total Employee-Hours Worked
26th%20Annual%20Safety%20Awards%20of%20Excellence%20Application.docx