Champion Membership

COMPANY INFORMATION

FORMAL COMPANY NAME:

Company name to appear on the membership charter, online and in marketing materials (leave blank if same as above):

Address

Phone

WEBSITE:

PRIMARY CONTACT Main person to receive all administrative correspondence including membership renewals, contact updates, event invitations, and LOC news.

NAME:(Required)

JOB TITLE:

PHONE:

CELL:

EMAIL:(Required)

Complete if different than company information (above):

Address

SENIOR EXECUTIVE

NAME:

JOB TITLE:

PHONE:

CELL:

EMAIL:

Health & Safety Representative

NAME:

JOB TITLE:

PHONE:

CELL:

EMAIL:

HEALTH & SAFETY PROGRAM

Does your organization belong to any professional associations? If so, please list below:

Is your company currently enrolled in or has been a member of the WSIB Health and Safety Excellence Program (HSEp)?

YES

If yes, please indicate the number of years in the HSEp program:

Is your company currently registered in, or has achieved COR®?

REGISTERED

CERTIFIED

Is your company currently pursuing, or has achieved the ISO 45001:2018 certification?

PURSUING

CERTIFIED

If your company is COR® and/or ISO 45001:2018 Certified, please include your certificate #’s:

Is your company enrolled in any other health & safety certification program(s)? If so, please explain below:

Please include a summary of your organization’s safety program and policies:

Has your company had a fatality assigned against its WSIB account within the last five years?

YES

If yes, please provide details and outcome:

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