THE CONNECTICUT SAFETY SOCIETY, INC.

Application for Membership

I, the undersigned, hereby make application for admission to THE CONNECTICUT SAFETY SOCIETY, INC.
I certify that the information given in this application is correct and I agree, if admitted as a member, to promote the objectives of THE CONNECTICUT SAFETY SOCIETY, INC. so far as shall be in my power.
(If additional space is needed for any category, please add an additional sheet.)

APPLICANT'S RECORD:

Full Name: ____________________________________________ DATE: _______________________

Present Occupation: ___________________________________________________________________
(Title/Position and Name of Company)

Length of service with company: Years: ____________ Months: ____________

Business Address: _____________________________________________________________________
Telephone No. (________)_______________________

Home Address: _______________________________________________________________________
Telephone No. (________)______________________

E-Mail Address: _______________________________________________________________________

Date and Place of Birth: _________________________________________________________________

General and Technical Education (School last attended and degree(s) conferred): ________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Membership in Professional Societies (Grade of membership and date of admission) _____________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

RECORD OF SAFETY SUPERVISORY, SAFETY ENGINEERING, OCCUPATIONAL HEALTH OR
RELATED EXPERIENCE: (Be specific as to nature of duties and dates)

From To Nature of Duties
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

RECORD OF OTHER OCCUPATIONAL EXPERIENCES:

From To Nature of Duties
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

REFERENCES:

Please provide the names and addresses of at least three people who have personal knowledge of your safety or safety related experience. At least one of these shall be a member of THE CONNECTICUT SAFETY SOCIETY, INC.

1.______________________________________________________________________________________
2.______________________________________________________________________________________
3.______________________________________________________________________________________

Please contact Denise Cassella, President CT Safety Society at 860-965-6398 should you have any questions.

APPLICANT'S STATEMENT:

If elected to membership, I hereby agree to conform to all of the requirements of the Constitution and Bylaws and to promote the interests of THE CONNECTICUT SAFETY SOCIETY at all times.

_______________________________________________________ Date: ________________________
(Signature of applicant)

A one time fee for application processing and first year of annual dues must accompany this application:
 
Total amount due: $50.00

The completed application and payment should be mailed to:

The Connecticut Safety Society, Inc.
c/o Thomas Schinkel, Treasurer
390 Brook Street
Bristol, CT 06010

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FOR SOCIETY USE ONLY

QUALIFICATIONS FOR MEMBERSHIP:

To be eligible for membership, an applicant who has been recommended by a member of
THE CONNECTICUT SAFETY SOCIETY, INC. shall be anyone who is actively engaged in safety, health or safety
related work in the state of Connecticut and whose primary responsibility included the reduction and control of accidents
and/or occupational diseases.

I hereby recommend this applicant: ___________________________ Date: ________________________
(Signature of SOCIETY member)

Approved by the Board of Directors on: _________________________ Attest: _________________________
(Date) (Secretary)

Approved by a quorum of members on: ________________________ Attest: _________________________
(Date) (Secretary)