ARKANSAS WORKERS’ COMPENSATION COMMISSION Form HS-31-A HS31-A HEALTH & SAFETY DIVISION 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-3930 / 1-800-622-4472 Ark. Code Ann. §11-9-409 & AWC C Rule 31 Rev. 1-1-2008 Application for (check all that apply) ‘ Approved Professional Safety Source (APSS) ‘ Field Safety Representative (FSR) (Note: Attendance at an on-site AW CC class is mandatory for APSS certification) Section 1. Personal Information 1) Name : Last: ____________________________________ 2) Telephone no.: 3) Social Security no.: Primary: (________) ______________________ Secondary: (_______) _____________________ 4) Total no. of years occupational health and safety experience :_____ 6) City: 7) State: First: ______________________MI: _______ 5) Mailing address: 8) Zip: 9) E-Mail address: Section 2. Professional Certifications Check all that apply. Enclose copy of current membership card. Information will be verified. Certification Certificate No. State (if applicable) ‘ Certified Safety Professional (CSP) ‘ Certified Industrial Hygienist (CIH) ‘ WSO Certification (specify Certified Safety Manager or Certified Safety Specialist) Section 3. Education and Professional Training Note: A certified transcript m ust be se nt directly from the granting institution to the Arkansas W orkers’ Compensation Commission, Health and Safety Division, P.O. Box 950, Little Rock, AR 72203-0950, ATTN: FSR/APSS. College o r Un iversity City, State Attendance Dates (From/To) Sem . Hrs. Com pleted Major Degree Earned Section 4. Occupa tional Safety and H ealth Professional Experience Using Attachment 1, list each occupational health and safety work assignm ent in chrono logical orde r, beginning with prese nt position. Section 5. Signature I certify that the preceding statements, including attachments, are accurate to the best of my knowledge, and authorize the Arkansas W orkers’ Comp ensation Commission to verify the information. I understand that any falsification of information is this application, including attachments, may be ca use for rejection or withdra wal of the Field S afety Rep resentative and/or App roved Professio nal Safety Source designation. Applicant Signature: _________________________________________________ Date:______________ (please use ink) HS -31-A American LegalNet, Inc. www.FormsWorkflow.com HS-31-A Attachment 1 Occupational Safety and Health Work Experience Use a separate copy o f Attachment 1 for ea ch cha nge in p osition, regard less of whether o r not there was a chan ge in em ployers. 1) Name during employment: 2) Position with this employer:: 3) Employer: Name Telephone no.: ( ) Address: City: 4) Employment dates (Mo/Yr.): From:____/_____ To:____/_______ State: Zip: 5) Major product or service of this company: 6) Immediate supervisor: Name Telephone No.: ( ) 7) Description of occupational health and safety work experience. Indicate the percentage of your time spent in the following areas: _____ Hazard identification _____ Hazard evaluation _____ Hazard control design _____ Environmental _____ Safety & health program design _____ Safety & health program evaluation _____ Safety & health communication _____ Incident investigation _____ Safety training & education _____ Supervision of other health & safety professionals _____ Neither health & safety or environmental _____ Hazard control verification For the three (3) areas above where you spent the most time, provide a brief description of your work in those areas: HS -31-A American LegalNet, Inc. www.FormsWorkflow.com