Registration Date (MM/DD/YYY)

WorkSafeBC Account Number/s

Legal Name of Company (registered with WorkSafeBC)

Operating Name

Number of FTEs
(FTE: full-time employees)

Number of Operating Locations

Classification Unit

Classification Unit 2 (if applicable)

Classification Unit 3 (if applicable)

Classification Unit 4 (if applicable)

First & Last Name of Company Contact

Title of Company Contact

Company Address

Email

Company Phone Number

Company Fax Number

I have read and agreed to the Terms of Participation and wish to participate in AgSafe's Certificate of Recognition Program

I commit that our company will endeavour to develop our OHS Program to the AgSafe COR Standard, to achieve Certification