Enews Registration Form

Health & SafetEnews Registration Form

Personal Information

Name

(First)	(Last)
Home Address
(Street)
(City)
(Prov/State)
(Postal Code) (ZIP Code)
(Country)
Email Address *
If you live in Ontario, what area?
Central Ontario Eastern Ontario North Eastern Ontario North Western Ontario Northern Ontario South Central Ontario South Western Ontario
In the last three years, have you taken any Occupational Health and Safety Training? Yes No
Are you a WHSC trained Instructor? Yes No

Workplace Information

Work Status

Non-union worker
Union member

(Union) (Local)
Management

(Position)

Are you?

JHSC member/health & safety Representative
Certified JHSC member/health & safety Representative
Union staff (Position)
Elected union representative (Position)

Which sector best applies to your workplace?

Accommodations & food service Construction Education Forestry & agriculture Health care & social assistance Mining/oil & gas extraction	Power, gas & water utilities Public administration Retail Telecommunications & publishing Transportation & warehousing
Manufacturing (select one below if applicable)
	Food & beverage Machinery & equipment Paper & printing Petroleum & chemical Primary & fabricated metals

*NOTE: By submiting this form you authorize the Workers Health and Safety Centre to communicate with you by means of Health & SafetEnews© using email.