Outreach Services Request Form NOTE: Before completing this form, please read the instructions on "Outreach Services and Procedures" to request educational services on workplace safety and health issues. Please provide as much information as possible to help facilitate your request. Items in red are required for submission. Please do not use this form to request LABOR ONE. Please visit the LABOR ONE webpage for information related to this mobile training unit. a. Requesting organization name: Complete mailing address: Telephone #: (include area code) Fax #: (include area code) b. Contact person: Company: Mailing Address: Yes No Same as above OR Telephone #: Yes No Same as above OR Fax #: Yes No Same as above OR E-mail address: c. Location and physical/street address (not mailing address, i.e. P.O. Box) of speaking engagement/exhibit/display booth. (Provide detailed directions if possible:) Telephone #: Yes No Same as above OR d. Outreach services desired: Training Presentation(s) Display booth/exhibit Speech e. If requesting training, OSHNC presentation topic(s) desired: (if you are not requesting training or a speech please but NA in this box) f. Language desired: English Spanish g. Date and time of presentation/exhibit (Please provide two or more dates, if possible): 1st Date: 1st Time: 2nd Date: 2nd Time: 3rd Date: 3rd Time: h. Length of presentation/exhibit: (For training, allow at least one hour per subject to provide detailed information. Presentations, however, can be altered to provide overviews with less detail.) i. Approximate number of attendees (minimum of ten for training): j. Audio-visual equipment requestor can provide: LCD Projector Overhead Projector VCR Screen White board Flipchart Other/Specify k. Other information available/necessary, such as hotel reservation information, conference confirmation requirements, special instructions, etc: For more information, please contact: Marcy Collyer at 919-807-2896 or Training.Request@labor.nc.gov Fax #: 919-807-2876 If you desire a copy of this information, please select FILE and then PRINT in your browser bar prior to submitting. Press SUBMIT only once to send this form.
Outreach Services Request Form
NOTE: Before completing this form, please read the instructions on "Outreach Services and Procedures" to request educational services on workplace safety and health issues. Please provide as much information as possible to help facilitate your request. Items in red are required for submission. Please do not use this form to request LABOR ONE. Please visit the LABOR ONE webpage for information related to this mobile training unit.
a. Requesting organization name: Complete mailing address: Telephone #: (include area code) Fax #: (include area code) b. Contact person: Company: Mailing Address: Yes No Same as above OR Telephone #: Yes No Same as above OR Fax #: Yes No Same as above OR E-mail address: c. Location and physical/street address (not mailing address, i.e. P.O. Box) of speaking engagement/exhibit/display booth. (Provide detailed directions if possible:) Telephone #: Yes No Same as above OR d. Outreach services desired: Training Presentation(s) Display booth/exhibit Speech e. If requesting training, OSHNC presentation topic(s) desired: (if you are not requesting training or a speech please but NA in this box) f. Language desired: English Spanish
g. Date and time of presentation/exhibit (Please provide two or more dates, if possible):
h. Length of presentation/exhibit: (For training, allow at least one hour per subject to provide detailed information. Presentations, however, can be altered to provide overviews with less detail.)
i. Approximate number of attendees (minimum of ten for training): j. Audio-visual equipment requestor can provide: LCD Projector Overhead Projector VCR Screen White board Flipchart Other/Specify k. Other information available/necessary, such as hotel reservation information, conference confirmation requirements, special instructions, etc:
For more information, please contact: Marcy Collyer at 919-807-2896 or Training.Request@labor.nc.gov Fax #: 919-807-2876
If you desire a copy of this information, please select FILE and then PRINT in your browser bar prior to submitting.
Press SUBMIT only once to send this form.
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