Dues Notice

JEFFERSON COUNTY AREA SAFETY NETWORK – www.jeffersonsafetynetwork.org

2018 – 2019 Dues Notice & Contact Update

Note:  Due date for membership is September 13, 2018

BUSINESS/COMPANY:      ______________________________________________________

PRIMARY CONTACT:        ______________________________________________________

TITLE/POSITION:                ______________________________________________________

MAILING ADDRESS:         ______________________________________________________

BUSINESS PHONE:             (________)________________FAX: (________)______________

E-MAIL:                                 ______________________________________________________

E-MAIL ADDRESSES: (Additional company contacts)
Note:  Please provide as many e-mail addresses as appropriate for your organization.

NAME E-MAIL ADDRESS

Not a member but would like meeting notices and safety/health updates—include your e-mail address.

2018– 2019 annual dues are $75.00 per company.  This allows each company/member to send as many employees to meetings as desired at the $15.00 rate per person attending.

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MAILING ADDRESS:
Checks should be made out to and returned with this membership form to:

Jefferson County Area Safety Network
C/o Mary Hughes
P.O. Box 297
Fort Atkinson, WI 53538

(920) 568-6543  —  Mary.Hughes@forthc.com