Section 1 of 6 in this document

IOSHA Request to Participate in Cooperative Program

Partner with IOSHA!

Type of Cooperative Program

Alliances

Partnership Program

Voluntary Protection Program

Employer Information

Employer Name

First Name

Last Name

Phone Number

Fax Number

Section 2 of 6 in this document

Worksite Address(es)

Section 3 of 6 in this document

Project Description

Section 4 of 6 in this document

Total Number Employees at Primary Site

Total Number of Employees Nationwide

NAICS Code/Business Type

Section 5 of 6 in this document

Have you had an OSHA enforcement visit in the last 12 months?

Yes

Union Representation

Yes

Union Name

Name of Union Contact

Phone Number