Missouri > Workers Comp
Application For Certification - Safety Consultant-Safety Engineer LSWSP-10 - Missouri
| Application For Certification - Safety Consultant-Safety Engineer Form. This is a Missouri form and can be used in Workers Comp . |
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MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS MISSOURI WORKERS' SAFETY PROGRAM APPLICATION FOR CERTIFICATION Safety Consultant / Safety Engineer P.O. Box 449 Jefferson City, MO 65102-0449 573-751-3403 www.labor.mo.gov/DLS Pursuant to RSMo 287.123 and 8 CSR 50-7.060, the following information is required in order to process an application for certification of Safety Engineers and Consultants. If applicant is found qualified for certification, the Missouri Workers' Safety Program will provide a letter which states the individual has met the qualification for inclusion on the Registry of Safety Engineers and Consultants. When applying for certification as a safety engineer, applicant must be licensed by the Missouri Board for Architects, Engineers, Surveyors, and Landscape Architects. PART I: PERSONAL INFORMATION APPLICATION FOR: DATE Safety Engineer NAME DATE OF BIRTH Safety Consultant PRESENT EMPLOYER SEX TITLE OF POSITION Male HOME ADDRESS (Street, City, State, ZIP) Female BUSINESS ADDRESS (Street, City, State, ZIP) HOME PHONE FAX E-MAIL BUSINESS PHONE Do you prefer to receive correspondence at: Have you been a defendant in a civil suit involving your professional activity or conduct? Are you a United States citizen? Yes No Yes Home No Work If "Yes," you must provide a certified copy of the judgment. If the case is not final, you must provide a certified copy of the complaint and the clerk's docket sheet. Are you a legal alien? Have you been convicted of a felony during the 10 years Yes No proceeding this application? Yes No Upon certification, your name will be placed on the Missouri Registry of Safety Professionals. The Registry is available upon request to any Missouri employer. Employers use the Registry as a resource when seeking consultation services. Do you wish to be identified as an available consultant/engineer? Yes No If "Yes," please provide your area(s) of expertise: PART II: PROFESSIONAL REGISTRATION OR CERTIFICATION Please check each applicable item. Enclose a copy of current registration or certification. Information is subject to verification by the Missouri Workers' Safety Program. Registered Professional Engineer Certified Safety Professional Certified Industrial Hygienist Certified Occupational Health Nurse Certified Occupational Health Physician REGISTRATION # CERTIFICATE # CERTIFICATE # CERTIFICATE # CERTIFICATE # STATE ISSUED BY ISSUED BY ISSUED BY ISSUED BY LSWSP-10 (05-12) AI American LegalNet, Inc. www.FormsWorkFlow.com PART III: COLLEGE EDUCATION The applicant is responsible for requesting and submitting an authenticated copy of their diploma/certificate OR transcript from each college or university. Transcripts must be received by the Missouri Workers' Safety Program directly from the college or university. College/University City and State Dates Attended Hours/Years Completed Major Degree Earned Check here if you are requesting an exemption from academic requirements. PART IV: OCCUPATIONAL SAFETY AND HEALTH EXPERIENCE (Be sure this part of the application shows three current/consecutive years of safety related consultation/work experience - attach additional sheets as needed.) Employers may be contacted to verify information provided. Please list each position in chronological order beginning with your present position. Account for all occupational safety and health experience in the last three years. Attach additional sheets if necessary. EMPLOYER DATE OF EMPLOYMENT TITLE ADDRESS TYPE OF BUSINESS SUPERVISOR'S PHONE NUMBER SUPERVISOR'S E-MAIL ADDRESS to SUPERVISOR'S NAME EMPLOYER WEBSITE DESCRIPTION OF EXPERIENCE Safety & Health Administration and Management Safety & Health Training and Education Accident Investigation and Statistical Reporting Safety & Health Program Evaluation Safety & Health Program Design Hazard Identification Hazard Elimination and Control Environmental Protection Other (describe) INDICATE THE PERCENTAGE OF TIME SPENT IN THE FOLLOWING AREAS (Total shall not exceed 100%.) For the three areas in which you spend the most time, please provide a brief description of your duties and give specific examples. LSWSP-10-2 (05-12) AI American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYER DATE OF EMPLOYMENT TITLE ADDRESS TYPE OF BUSINESS SUPERVISOR'S PHONE NUMBER SUPERVISOR'S E-MAIL ADDRESS to SUPERVISOR'S NAME EMPLOYER WEBSITE DESCRIPTION OF EXPERIENCE Safety & Health Administration and Management Safety & Health Training and Education Accident Investigation and Statistical Reporting Safety & Health Program Evaluation Safety & Health Program Design Hazard Identification Hazard Elimination and Control Environmental Protection Other (describe) INDICATE THE PERCENTAGE OF TIME SPENT IN THE FOLLOWING AREAS (Total shall not exceed 100%.) For the three areas in which you spend the most time, please provide a brief description of your duties and give specific examples. LSWSP-10-3 (05-12) AI American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYER DATE OF EMPLOYMENT TITLE ADDRESS TYPE OF BUSINESS SUPERVISOR'S PHONE NUMBER SUPERVISOR'S E-MAIL ADDRESS to SUPERVISOR'S NAME EMPLOYER WEBSITE DESCRIPTION OF EXPERIENCE Safety & Health Administration and Management Safety & Health Training and Education Accident Investigation and Statistical Reporting Safety & Health Program Evaluation Safety & Health Program Design Hazard Identification Hazard Elimination and Control Environmental Protection Other (describe) INDICATE THE PERCENTAGE OF TIME SPENT IN THE FOLLOWING AREAS (Total shall not exceed 100%.) For the three areas in which you spend the most time, please provide a brief description of your duties and give specific examples. I certify that the statements above, including any attachments submitted, are accurate to the best of my knowledge. I hereby authorize the Missouri Workers' Safety Program to verify any information submitted. I understand that any falsification of information in the application, or statements, may be cause for rejection or withdrawal of certification. I further agree to hold the Missouri Workers' Safety Program harmless from any and all liability in the event this application is rejected on the basis of information furnished to the Missouri Workers' Safety Program by me or third persons which would, in the judgment of the Missouri Workers' Safety Program, make me ineligible for certification. Notary Seal SIGNATURE Notary Signature DATE SIGNATURE MUST BE NOTARIZED LSWSP-10-4 (05-12) AI American LegalNet, Inc. www.FormsWorkF
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