New Jersey State Industrial Safety Committee

New Jersey State Industrial Safety Committee (NJSISC) Membership Application

Directions: 1. Complete page one (sections 1-5) and return with a resume to the Membership Chairperson. 2. Ask a current NJSISC Member to complete the recommendation on page two and email to the below Membership Committee Member.

Membership Committee Member: Patrick Mulrooney [email protected]

1. Applicant Name

First: Last:

2. Work Information

Company Name: Street Address: Town: State Zip Job Title: Cell phone optional County: Phone: Fax: Email:

List other safety-related organizations you are currently active in:

List up to four areas of expertise (For example: General Safety, Regulations, Computers, Training, Electrical Safety, Industrial Hygiene, etc.)

3. Home Information

Street Address: Town: Zip County: Phone: State: Email:

4. Mail Preference (put x by one) home work

5. Committee Assignment

Select a Committees That You Would Like To Join: Please note that this in an Active Committee and requires participation in at least one of the below Committees. For more information on any committee please contact the Membership Chairperson listed above.

Area Dinner (Governors Safety Award) Safety Training/Professional Development Membership Safety Promotion

of 2 JUNE 2009 New Jersey State Industrial Safety Committee Membership Recommendation Form

Directions: Complete and return to: Patrick Mulrooney [email protected]

Applicant Name

Recommendation: (Please include how long you’ve known the applicant, in what capacity, reasons for recommending membership, etc.)

Member Name: Date:

Member Signature: (retype name if sending electronic)

For Office Use Only

1. General Membership approved to forward to Commissioner of LWD requesting membership (date)

2. Membership Date

3. Date voted on by the General Membership to forward to Commissioner of Labor and Workforce Development

4. Disapproved to offer membership (date)

5. Committee Assignment

6. Chairperson of Committee

7. County Assignment

8. At-large Assignment

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