Membership Application

U.S. & Canada

Organizational membership is available to all types of employers, including industries, business associations, federal, state and local governments, nonprofit organizations, schools, universities, colleges and unions.

Please print this application, complete all sections, and return it to the National Safety Council along with your dues payable in U.S. funds. You may pay with a credit card, check made payable to the National Safety Council, or with a documented Purchase Order.

Mail to:
National Safety Council
3241 Paysphere Circle, Chicago IL 60674
Fax to: 630-285-9288
E-mail: customerservice@nsc.org
800-621-7619

If located outside the U.S. & Canada, please click here to complete the International Application.

Organization/Company Information
Organization/Company Name
Street Address
City
State
Zip/Postal Code
P.O.Box
City
State
Zip
	Check here if all mail must go to the P.O.Box
Main Phone
Main Fax
Website (optional)
Total number of full-time Employees (including drivers)	( Used for Calculating dues level )
Please check if you prefer NOT to recieve:	NSC electronic/fax communications
Contact Information
Primary Safety & Health Contact (for benefit fulfillment)
Name
Title
Phone
E-mail
Executive Management Contact
Name
Title
Phone
E-mail
Additional Contact
Name
Title
Phone
E-mail
Organization Location Information
If your membership is to include additional facilities and/or offices other than the location listed above, please indicate the number of additional locations below. Please attach a separate listing of each organization name, contact name, title, address, city, state, zip code, phone, fax and e-mail address. Or fax this list to 630.285.9288.
Number of additional locations (facilities and/or offices) included in this Membership
Publication Selection
Please select one of the following.
OSHA Up To Date Newsletter (via e-mail)
OSHA Up To Date Newsletter (printed)
Traffic Safety Newsletter (via e-mail)
Traffic Safety Newsletter (printed)
For e-mail format: Content is copyright protected and may not be forwarded to other e-mail addresses
Gift Code
To receive your free gift, please enter the gift code from NSC communication you have received or select one from our onlinefree offers .                                     Gift Code ___________________________________________________
Membership Dues
Calculate your membership dues based on the number of employees within your organization. Employees Rate (U.S. dollars) 1-10 $270.00 11-49 $305.00 50-99 $340.00 100+ $360.00 + $1.00 per additional employee over 100 (max. $18,000)
Payment Formula
Base Dues (See chart above ) $__________ First 100 Employees +___0.00___ Additional Employees over 100 _________________          _____$1.00______ No. of Employees over 100    X   Rate per Employee + $__________    Additional Dues Total Annual Dues = $_________ NOTE: Dues are capped at $18,000 for organizations with employee counts                     of 17,740 or greater. Membership dues are non-refundable.
Payment Options
Bill my credit card.
Credit Card	Visa MasterCard AmEx Discover
Credit Card Number
Expiration date (MM/YY)
Name as it appears on card
Signature
Check enclosed (made payable in U.S. funds to National Safety Council). Check No.__________
Purchase order.        (Requires documentation of purchase order attached. Net 30 days/NSC will invoice in U.S. funds.)
PO Number
Questions? Call 1-800-621-7619 or e-mail us at customerservice@nsc.org.
Thank you.