Registration Date (MM/DD/YYY)

WorkSafeBC Account Number/s

Legal Name of Company (registered with WorkSafeBC)

Operating Name

Number of FTEs
(FTE (full‐time equivalent employees) is calculated by dividing the total annual payroll hours by 2000.)

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