Your Name (required)

Your Email (required)

WorkSafeBC Account Number

Legal Name of Company as registered with WSBC (required)

Operating Name of Company (if different from legal name)

Number of Employees (required)

Number of Operating Locations (or Number of Crews)

Classification Unit(s)

Full Name of Company Contact (required)

Company Contact's Position (required)

Company Contact's Email Address (required)

Company Address (required)

Company Phone Number (required)

Company Fax Number

Company Email Address (required)

I give permission to AgSafe (FARSHA) to send electronic messages including newsletters to the email addresses above

AgSafe (FARSHA) has permission to access all information related to the WorkSafeBC account identified above

Company Representative (required)

Company Representative's Position

Company Representative's Email (required)