Annual Certificate Renewal {WSP-11}

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS MISSOURI WORKERS' SAFETY PROGRAM ANNUAL CERTIFICATION RENEWAL Safety Consultant / Safety Engineer P.O. Box 58 Jefferson City, MO 65102-0058 573-526-5757 www.labor.mo.gov/DWC Pursuant to RSMo 287.123 and 8 CSR 50-7.080, consultants seeking re-certification must submit proof of continuing education annually. This application must be typewritten. If the applicant is found qualified for re-certification, the Missouri Workers' Safety Program (MWSP) will send an approval letter and continue to include the consultant's name on the Registry of Safety Consultants and Engineers. PART I: PERSONAL INFORMATION APPLICATION FOR: DATE Safety Engineer NAME DATE OF BIRTH Safety Consultant PRESENT EMPLOYER TITLE OF POSITION BUSINESS ADDRESS (Street, City, State, Zip) HOME ADDRESS (Street, City, State, Zip) HOME PHONE PERSONAL E-MAIL WORK E-MAIL BUSINESS PHONE FAX Do you prefer to receive correspondence from the MWSP at: Have you been a defendant in a civil suit involving your professional activity or conduct? Yes No Home 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. Upon certification, your name will be placed on the Missouri Registry of Safety Professionals. The Registry is available online and upon request to any Missouri employer. Employers use the Registry as a resource when seeking consultation services. Which contact information do you prefer to be used on the registry? Home Work Do you wish to be identified as an available independent consultant/engineer? Yes No If "Yes," please provide your area(s) of expertise: PART II: CHANGES AND UPDATES Please provide in the space below any updates, additions, or changes to your certifications, education, or safety and health experience that have occurred during the last year. Attach documentation or certificates where necessary. WSP-11 (08-13) AI American LegalNet, Inc. www.FormsWorkFlow.com PART III: PROOF OF CONTINUING EDUCATION Attach proof of one continuing education unit (CEU) obtained within the last year. One CEU is 10 contact hours of instruction. One contact hour equals 50 minutes. It must be related to occupational safety and health. Acceptable topics include safety management, industrial hygiene, industrial safety, general safety, driver safety, fire safety, aviation safety, transportation safety, occupational safety and health administration, accident and statistical reporting, safety training, safety engineering, system safety analysis, construction safety, legal and ethical issues related to safety, chemical or biological safety, or environmental safety. If you are using courses that have not been preapproved or provided with CEUs, then the documentation must include the topics presented and the length of time of the class. If you are using a conference to meet this education requirement, you must indicate which individual sessions you attended. 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 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 Missouri Division of Workers' Compensation is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. WSP-11-2 (08-13) AI www.FormsWorkflow.com