Form Hs-31-A - Application Form For Approved Personal Safety Source/field Safety Representative - Arkansas

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ARKANSAS WORKERS’ COMPENSATION COMMISSION
Form HS-31-A
HS-
Ark. Code Ann. §11-
HEALTH & SAFETY DIVISION
9-409 & AWCC
324 Spring Street, Little Rock, AR 72201
31-A
Rule 31
Mail: P. O. Box 950, Little Rock, AR 72203-0950
Rev. 1-1-2008
501-682-3930 / 1-800-622-4472
Application for (check all that apply)
‘Approved Professional Safety Source (APSS)
‘Field Safety Representative (FSR)
(Note: Attendance at an on-site AWCC class is mandatory for APSS certification)
Section 1. Personal Information
1) Name (include all names referenced in submitted materials):
2) Telephone no.:
3) Social Security no.:
Last: ____________________________________
Primary: (________) ______________________
4) Total no. of years occupational health
First: ______________________MI: _______
and safety experience :
_____
Secondary: (_______) _____________________
5) Mailing address:
6) City:
7) State:
8: Zip:
9)E-Mail address:
Section 2. Professional Certifications
Check all that apply. Enclose copy of current membership card. Information will be verified.
Certification
Certificate No.
State (if applicable)
‘ Certified Safety Professional (CSP)
‘ Certified Industrial Hygienist (CIH)
‘ WSO Certification ( specify Certified Safety Manager or
Certified Safety Specialist)
Section 3. Education and Professional Training Note: A certified transcript must be sent directly from the granting institution
to the Arkansas Workers’ Compensation Commission, Health and Safety Division, P.O. Box 950, Little Rock, AR 72203-0950,
ATTN: FSR/APSS.
College or University
City,
Attendance Dates
Sem. Hrs.
Major
Degree
State
(From/To)
Completed
Earned
Section 4. Occupational Safety and Health Professional Experience Using Attachment 1, list each occupational health and safety
work assignment in chronological order, beginning with present position.
Section 5. Signature
I certify that the preceding statements, including attachments, are accurate to the best of my knowledge, and authorize the Arkansas
Workers’ Compensation Commission to verify the information. I understand that any falsification of information is this application,
including attachments, may be cause for rejection or withdrawal of the Field Safety Representative and/or Approved Professional
Safety Source designation.
Applicant Signature: _________________________________________________ Date:______________
(please use ink)
HS-31-A

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