Safety Advice Line Application Form Company Name * Company Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Main Contact Name * Main Contact Telephone * Main Contact Email * Company Type * Limited Company Sole Trader Partnership Do you operate as: Main Contractor Sub Contractor Expected annual turnover: * Number of Employees Health and Safety Rep Name: Details of the Director responsible for safety matters in your company Position Do you have a health and safety policy? Yes No Please provide details of any safety training provided to your employees and supervisors in the past 12 months: Has any HSE enforcing action been taken against your company (Improvement or Prohibition Notices or prosecutions) over the past three years? * Yes No If yes, please provide details of further details: How many active projects are ongoing? * Declarations: I / We Hereby Apply For Membership Of The Eastern Builders Safety Group Limited (The Group) And By Signing this Declaration Confirm That: I / We have read and agree to be bound by the memorandum and articles of association and by-laws of the group for the time being. I / We agree to pay my / our subscription in accordance with the memorandum and articles of association and understand that the current rate of subscription for Full Membership is calculated by reference to turnover. I / We have read and agree to the terms and conditions of membership. The information provided in this form is true and correct to the best of my / our knowledge. I / We agree to return the following documentation with this application, if applicable: ✓ Details of our notifiable accident record for the last 3 years ✓ Copy of our current health & safety policy Declaration Agreement * I / We agree Thank you!We will be in touch shortly……..
