Simply fill out this form and click the Place Order button.

Please select your choice of DVD/PowerPoint    or    Video cassette

Where should we send your FREE safety materials?

Name

Title

Company Name

Shipping Address
(no PO Boxes)

City

State

Zip

Daytime Phone#:

Number of employees including owner:

0-5    6-10    11-20    21-50    51+

Years company has been in business:

0-5    6-10    11-20    21-50    51+

Primary business activity (i.e. roofing, excavation, plumbing):

Would it be helpful to receive safety materials in languages other than English and Spanish?

Yes     No

Please specify what other languages you need and how many employees speak each language.

Language 1: Quantity:

Language 2: Quantity:

Language 3: Quantity:

How will you use this safety training kit? (Check all that apply)

Safety meeting  Tailgate meeting New employee orientation

Other (please explain)

Are there any specific issues you would like us to address in future safety materials? Other comments?

Please provide your email address if you would like to receive special safety-issue notifications from SMUD. (We will not give your email address to anyone else.)