Health and Safety Excellence Program Registration Form

Thank you for your interest in the Health and Safety Excellence program. When registering, be aware that you can work on up to five topics per program year (a minimum of one must be selected when you begin).

Registration fees (depending on size of firm):

1 to 19 employees $700
20 to 99 employees $1,500
100 + employees $2,500

Note: If providing a purchase order is not an option, payment with a credit card can occur instead. Please contact Rony at ronymonayeem@workplacesafetynorth.ca for credit card transactions.

WSIB firm #:

WSIB account #:

HP code (if applicable):

Registration date:

Program lead name:

Secondary program support name:

Senior manager name:

Telephone:

Email:

Billing information:

Company legal name:

Company address:

City

Postal code

Company telephone:

*Purchase order number if required on the invoice, please provide:

Name of person invoice is to be sent:

Number of workers:

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