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    Wise Application-Fillable

    Uploaded by

    Ade Azhar Basir
    The document is an application form for a safety program with multiple levels. It requests information about the applicant such as company details, contact information, and the level they are applying for. It certifies the accuracy of the information and provides contact information for questions about the application or safety program process.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Wise Application-Fillable

    Uploaded by

    Ade Azhar Basir
    12 views1 page
    The document is an application form for a safety program with multiple levels. It requests information about the applicant such as company details, contact information, and the level they are applying for. It certifies the accuracy of the information and provides contact information for questions about the application or safety program process.

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    wise_application-fillable (1)

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    The document is an application form for a safety program with multiple levels. It requests information about the applicant such as company details, contact information, and the level they are applying for. It certifies the accuracy of the information and provides contact information for questions about the application or safety program process.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    12 views1 page

    Wise Application-Fillable

    Uploaded by

    Ade Azhar Basir
    The document is an application form for a safety program with multiple levels. It requests information about the applicant such as company details, contact information, and the level they are applying for. It certifies the accuracy of the information and provides contact information for questions about the application or safety program process.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

     

     
    APPLICATION FORM
     

     
     

    Applying for:                     LEVEL I                                  LEVEL II                        LEVEL III          APPLICATION FEE: $250


     
     

    Annual fee to be invoice


     
     
     

    Membership Type:                  General Contractor                           Specialty (Subcontractor)  pro-rated Nov. 1st – Oct. 31st


     
     
     

    Date of Application:                                                Select One:                New Applicant                   Renewal 
    Company Name: 
     
    Address: 
     
    City/State/Zip: 
     
    Phone Number                                                                       Fax Number: 
     
    Company Principal/Owner:                                                  Company Safety Contact: 
     
    Company Contact to coordinate program and jobsite audits for evaluation completion 
     
    Contact Phone Number:                                                      Contact E‐Mail: 
     
    I hereby certify that all information provided within this application is accurate. 
    Person completing this application: 
     

    Name: ____________________________________   Title: _______________________________________ 
     
    Signature: _______________________________________________________   Date: _________________________ 
     

    If you have any questions regarding this application, or this AGC  Safety Program process, please contact the AGC Safety Director 
    at 608‐221‐3821 
     
    AGC Use Only                  Insert Date Completed: 
     
    Application                       Checklist                               Program Audit                 Jobsite Audit        Attained Level           AGC Note
                                                                                                                                                                      I.        II.        III. 
    Congrats Letter                Plaque/Certificate               Decals                               Banner       
                      
                                                                                                       

     Revision Date:   December 2016  
                                                                                                                                                                                                                                                                                                                                                                                                                                                               

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