JEFFERSON COUNTY AREA SAFETY NETWORK
www.jeffersonsafetynetwork.org

2011 – 2012 Dues Notice & Contact Update

Note: Due date for membership is September 8, 2011

BUSINESS/COMPANY: __________________________________________________________________

PRIMARY CONTACT: ____________________________________________________________________

TITLE/POSITION:  ______________________________________________________________________

MAILING ADDRESS:  ____________________________________________________________________

BUSINESS PHONE: (_______)_____________FAX: (_______)_____________

E-MAIL: ________________________________________________________

E-MAIL ADDRESSES: (Additional company contacts)
Note: Please provide as many e-mail addresses as appropriate for your organization.

NAME	E-MAIL ADDRESS

Not a member but would like monthly meeting notices and safety/health updates—include email address above.

The 2011 – 2012 annual dues are $100.00 per company. This allows each company/member to send as many employees to meetings as desired.

******************************************************************************

Special Prize Drawing:
For every member attendee that pre-registers and attends a session, the company will be entered into a drawing. Drawing: March 8, 2012 session. Prize: Full paid two-day registration fee to attend the WSC Congress event held April 17^th & 18^th, 2012 at the Kalahari, Wisconsin Dells.
Prize Value: approx. $370/each. Three will be given away.

******************************************************************************

MAILING ADRESS:
Checks should be made out to and returned with this membership form to:

Jefferson County Area Safety Network
C/o Mary Hughes
P.O. Box 297
Fort Atkinson, WI 53538
(920) 568-6543