35+ YEAR SAFE MINING AWARD

35+ YEAR SAFE MINING AWARD NOMINATION FORM

Use this form to nominate persons within your organization that have worked 35+ years, consecutively, without a Lost Time Injury. The recipients will be recognized and presented with an award. The nominee will be recognized on the SCJMHSC website and during the 2022 South Central Joint Mine Health & Safety Conference. The conference is scheduled for April 18-21,2022. Please complete one form for each nominee** and return to: South Central Joint Mine Health Safety Conference scjmhscassociation@gmail.com.

Entry Deadline is March 18, 2021

Please Select One*
Nominee*
First Last
Company*
Address*
Street Address Address Line 2 City State ZIP Code
Years Worked With No Lost Time Injury*
Please enter a number from 1 to 100.
Commodity Mined (list all that apply)*
Mine Type - Surface or Underground*
Details*
Please Give Details Why Nominee Should Be Considered
Person Completing This Form*
First Last
Email*
Phone # (for nominee verification)*
Award Recipient Registration Fee*
Price:
Credit Card
Card Details
Cardholder Name

35+ YEAR SAFE MINING AWARD

35+ YEAR SAFE MINING AWARD NOMINATION FORM

Entry Deadline is March 18, 2021

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