Safety Awards Please complete this form to apply for an STI/SPFA Safety Award. All fields are required. Select the award(s) you are submitting for: Safety Diamond Club Award Safety Award of Excellence Safety Award of Achievement Check applicable employer size: 100+ Employees – 1,000,000 Manhours 61-99 Employees – 650,000 Manhours or 5 years 31-60 Employees – 450,000 Manhours or 5 years 10-30 Employees – 250,000 Manhours or 5 years Contact Information - Person responsible for maintaining records of workplace injuries and illnesses for MEMBER EMPLOYER, and to whom plaque and hardhat decals (see below) should be sent.First Name:(Required) Last Name:(Required) Title:(Required) Company Name:(Required) Address (Plaques cannot be shipped to a PO Box):(Required) City:(Required) State/Province:(Required) Zip/Postal Code:(Required) Phone:(Required) Email:(Required) Contact Information - Person responsible for management of this MEMBER EMPLOYER facility:First Name:(Required) Last Name:(Required) Title:(Required) Select the type of recognition you would like (choose only one):(Required) Plaque ($150 per plaque) Framed certificate (complimentary for the first certificate and each additional at cost plus shipping) Name of member company/employer EXACTLY as it should appear on any recognition:(Required) Number of hardhat decals requested:(Required)Decals are provided at a cost of $0.60 ea. plus shipping, and are invoiced at the time of shipment. Unless otherwise indicated, the plaque and hardhat decals will be shipped to the individual named above as recorder of workplace injuries and illnesses for the member employer facility.By submitting this form you certify that all information is factual and true for the member employer, and if asked, can provide verification of this information.(Required) I agree to submit this form as a representative of the member employer. Δ
