Educational Services Enrollment/Quote Form
(Fill out all form boxes to calculate your total program cost prior to enrolling.)

GENERAL INFORMATION FOR ON-LINE TRAINING:

*For more information on becoming a Medical Society member and to receive member discounts.

Contact Name:
Phone:	Ext.:
E-mail:
Name of Organization:
Address:
City:	State: Zip:
Total # of Employees:
Other Facilities In Organization:

SAFEASSURE ANNUAL MEMBERSHIP:

• 1-800-920-SAFE - OSHA Consulting/Questions - Phone SafeAssure

• "SafeAssure ALERT" Bulletins

• Full Society Discount on all SafeAssure Services/Products

• Updates to your SafeAssure Safety Programs

SAFEASSURE ANNUAL MEMBERSHIP = $199

SAFEASSURE SIMULATED O.S.H.A. INSPECTION & PROGRAM ANALYSIS FOR STATE OF MINNESOTA ONLY:

• On Site Building Inspection & Analysis of Current Programs/Procedures

• Confidential Written Report with Recommendations

Initial Inspection & Report for One Facility = $275

Additional Site Inspections x $100 =

O.S.H.A. CLINIC INSPECTIONS & REPORTS = (click in box to calculate total)

SAFEASSURE ANNUAL ON-LINE TRAINING:

Annual Set-Up Fee = $125

# Of Employees x $10 =

ON-LINE TRAINING = (click in box to calculate total)

SAFEASSURE SITE SPECIFIC SAFETY PROGRAMS:

	A.W.A.I.R.	$125
	E.R.T.K.	$125
	EMER. ACTION PLAN	$125
	BLOODBORNE PATH	$125
	ERGONOMICS	$125
	# OF SAFETY PROGRAMS x $125 (click in box to calculate total)
	PURCHASE ALL 5 PROGRAMS ABOVE ($75 Discount) $550 (check box and then click in box to calculate total)
	TOTAL COST FOR MEMBERSHIP & PROGRAMS = (click in box to calculate total)

AGREEMENT AUTHORIZED BY:

Name:
Title:
Purchase Order #:
Billing Address: City:	State: Zip:
Make sure all information is filled in and accurate before submitting form. Once form is submitted, you will be contacted by our SafeAssure staff to complete your enrollment process.