Safety Director of the Year Nomination | Wisconsin Motor Carriers Association Online Payment

Name of Nominee

First Last

Nominee's E-mail (if known)

Name of Spouse (if applicable)

First Last

Company

Street Address City State / Province / Region ZIP / Postal Code Country

Is the Nominee a Member of the WI Safety Management Council

Yes
No

How Many Years Has the Nominee Worked for Current Employer?

Please provide information regarding the safety record of the company (CSA scores, accident ratios, etc.)

Please provide any information regarding volunteer activities relating to the trucking industry.

Please provide information regarding any other volunteer activities.

Please provide information regarding any awards or honors received by the Nominee from current or past employers.

Please provide any other information that would qualify this candidate for Safety Director of the Year. (education, heroics, industry concern, image, etc.)

Nominator's Name and Title

Company

E-mail of Nominator

Nominator Verification*

I hereby certify that the above stae above candidattements are true and correct to the best of my knowledge. I understand that a false statement may disqualify the person for the Safety Director of the Year program. By checking this box, I certify I have read understand the contest rules and provided the required support documents.

Upload Any Pertinent Support Documents Here

Drop files here or

Max. file size: 1 MB.

Only Active Members of the WI Safety Management Council May be Nominated.

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