Annual Certification Renewal Safety Consultant Safety Engineer Form. This is a Missouri form and can be use in Workers Comp.
Tags: Annual Certification Renewal Safety Consultant Safety Engineer, LSWSP-11, Missouri Workers Comp,
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF LABOR STANDARDS MISSOURI WORKERS’ SAFETY PROGRAM ANNUAL CERTIFICATION RENEWAL Safety Consultant / Safety Engineer P.O. Box 449 Jefferson City, MO 65102-0449 573-751-3403 Re-certification is required annually. Proof of one Continuing Education Unit (ten contact hours of safety-related instruction) is required to be submitted upon application for renewal. A certificate or written notice on the organization’s letterhead is acceptable. The content of the course should be related to occupational safety and health, such as Environmental Health and Safety, Safety Program Administration and Management, General Occupational Safety and Health, Transportation Safety, Industrial Safety, Safety Engineering and Applied Science, etc. The Missouri Workers’ Safety Program reserves the right to contact the organization to verify the information provided. PART I: PERSONAL INFORMATION APPLICATION FOR: Safety Engineer DATE Safety Consultant NAME DATE OF BIRTH PRESENT EMPLOYER SEX TITLE OF POSITION Male Female HOME ADDRESS (Street, City, State, Zip) BUSINESS ADDRESS (Street, City, State, Zip) HOME PHONE BUSINESS PHONE FAX E-MAIL Do you prefer to receive correspondence at: Have you been a defendant in a civil suit involving your professional activity or conduct? Yes Home No Work If “Yes,” you must provide a certified copy of the judgment. If the case is not final, you must provide a certified copy of the complaint and the clerk’s docket sheet. Upon certification, your name will be placed on the Missouri Registry of Safety Professionals. The Registry is available upon request to any Missouri employer. Employers use the Registry as a resource when seeking consultation services. Do you wish to be identified as an available consultant/engineer? Yes No If “Yes,” please provide your area(s) of expertise: LSWSP-11 (08-11) AI American LegalNet, Inc. www.FormsWorkFlow.com PART II: PROFESSIONAL REGISTRATION OR CERTIFICATION Please indicate in the space below any changes, additions or alterations to previously reported professional registration or certification. PART III: OCCUPATIONAL SAFETY AND HEALTH EXPERIENCE Please provide in the space below any changes in your safety related job duties. If you have provided services as an independent consultant / engineer during the past year, please list below the employers you have assisted and the types of services you have provided. I certify that the statements above, including any attachments submitted, are accurate to the best of my knowledge. I hereby authorize the Missouri Workers’ Safety Program to verify any information submitted. I understand that any falsification of information in the application, or statements, may be cause for rejection or withdrawal of certification. I agree to hold the Missouri Workers’ Safety Program harmless from any and all liability in the event this application is rejected on the basis of information furnished to the Missouri Workers’ Safety Program by me or third persons which would, in the judgment of the Missouri Workers’ Safety Program, make me ineligible for certification. Notary Seal SIGNATURE Notary Signature DATE SIGNATURE MUST BE NOTARIZED LSWSP-11-2 (08-11) AI American LegalNet, Inc. www.FormsWorkFlow.com