Application for Drug-Free Safety Program Instructions You may submit the completed form in one of three ways listed below. 1. Apply online at ohiobwc.com 2. Fax it to 614-621-1405; or 3. Mail to: Attention: Employer Programs Ohio Bureau of Workers’ Compensation 30 W. Spring St., 22nd Floor Columbus, OH 43215-2256 Employer information Name of employer and DBA Federal tax ID number Address City Our company has Internet access, and correspondence may be sent to us at the email address below. Yes n State BWC policy number ZIP code Fax number No n Email address for drug-free contact person Telephone number Employer contact person for Drug-Free Safety Program (DFSP) Contact person’s telephone number Note While participating in the Drug-Free Safety Program, you should verify other BWC programs that are compatible with it. You may participate in more than one BWC program. However, only certain programs may be combined in the discount calculation. Please reference the compatibility chart found in Ohio Administrative Code 4123-17-74. Check the program/level for which you are requesting approval.  n Advanced level n Basic level n Comparable program Number of employees Do you want BWC to place you in the State of Ohio construction contractor/subcontractor database, thereby making you eligible to bid and/or work on state construction projects? (Employer wants to be listed as “approved” in state construction database.) Yes n No n I hereby certify my organization is applying to implement a DFSP pursuant to Rule 4123-17-58 of the Ohio Administrative Code. I also certify my organization is willing to meet, at minimum, the requirements associated with the level of program for which I have applied (Advanced, Basic or Comparable). This includes timely submission of a fully completed annual report, which BWC must receive by the deadline date or be postmarked by that date as specified by rule. When failing to fully implement the DFSP or meet the specified requirements, I agree to promptly repay to the BWC any DFSP discount received. Also, I certify this information is accurate and, if not, may subject the employer applicant and myself to civil and criminal penalties. Name of designated employer representative certifying intent to comply and willingness to pay back discounts for non-compliance. X Signature Date signed BWC-7646 (Rev. 2/22/2012) U-140 American LegalNet, Inc. www.FormsWorkFlow.com