Transportation Health and Safety Association of Ontario
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safe driver/safe worker award program enrollment  

Transportation Health & Safety Association of Ontario

555 Dixon Road, Suite 101, Etobicoke, Ontario M9W 1H8
Phone: (416) 242-4771; Fax: (416) 242-4714; INWATTS: 1-800-263-5016
E-mail: nov.dacres@thsao.on.ca
 

PLEASE ENROLL OUR COMPANY IN THE SAFE DRIVER/SAFE WORKER AWARD PROGRAM

Company Name:
Complete Street Address:
Postal Code: Phone:
Fax: Email:
Type of Business:
WCB Firm #: WCB Rate #:
Year Claiming Awards for:
Commercial - Dec 31,    School Bus - June 30,    Worker - Dec 31,
Number of Employees in Program: 
SURNAME GIVEN NAME DATE STARTED DRIVING FOR COMPANY DOES DRIVER HAVE AWARD? NO. YEARS YEAR AWARDED LIST YEAR OF ANY PREVIOUS ACCIDENTS NO. YEARS CLAIMING FOR DRIVER
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I/WE HEREBY CERTIFY THE DRIVERS LISTED ARE QUALIFIED FOR THE AWARD AS INDICATED AND HAVE BEEN EMPLOYED FOR THE PERIOD STATED.

Authorized Name:

CONTACT PERSON IF NOT THE SAME AS ABOVE (PRINT):