BUSINESS PROFILE Label
Business Name:
Mailing Address: City: State:
AL
Zip:
Physical  Address (if different): City: State:
AL
Zip:
                             
Number of Years in Business: Phone:   Fax:
NAICS/SIC: No. of Employees:
Company Website: Type of Product/Service:
CONTACT INFORMATION  (must provide all three contacts below)

(1) Membership Contact   (to be contacted for membership renewal)  
Name:
  Title:
Email:   Phone:   Fax:
Address:   City:   State:
AL
  Zip:

(2) Scheduling Contact   (to register employees for training/classes)  
   
Name:
  Title:
Email:   Phone:   Fax:
Address:   City:   State:
AL
  Zip:

(3) Accounts Payable Contact   (for payment or invoicing of training fees, upon credit approval)  
   
Name:
  Title:
Email:   Phone:   Fax:
Address:   City:   State:
AL
  Zip:


MEMBERSHIP PAYMENT  
Choose payment method:
Annual Amount:
         
PAYMENT METHOD FOR TRAINING
The method of payment (credit card, pay at door, invoice) is specified when students are registered for a class.  If you would like to request the ability to be invoiced, we will need to collect some additional information to process the request.  You must also be an active member in order to be invoiced, and this may affect that annual cost. Please check this box to request invoicing ability for future training.
       (Invoicing available upon credit approval )
   

REASONS FOR JOINING  (select all that apply)







   
   
     



CORPORATE - $355 PER YEAR

Available to anyone needing our full offering of benefits

  • Discounted training on BOP, COSS, Safe Supervisor, PowerSafe, first aid, CPR and more
  • Unlimited access to a secure online training records management system
  • Low-cost site, new hire and company-specific online course development through our e-learning team
  • 10-percent discount off of the catalogue price on materials from J. J. Keller
  • Unlimited access to our video library with over 1,000 titles
  • Member discount on registration for the Louisiana Governor’s Safety & Health Conference
  • Complimentary car seat inspection for employees and their families

SMALL BUSINESS - $149 PER YEAR

Available only to companies with 10 or fewer employees

  • Training discounts on select courses
  • Individual record lookup
  • Unlimited access to our video library with over 1,000 titles
  • Member discount on registration for the Louisiana Governor’s Safety & Health Conference
  • Opportunities for awards and recognition
  • Complimentary car seat inspection for employees and their families

* Upon credit approval, invoicing privileges are available to corporate-level members.

The annual amount has changed due to the invoicing request, which is a benefit of a Corporate Membership.
Your credit card has not been validated. You cannot submit your application until that occurs.