I wish to file an application for an SGA Motor Vehicle Award by certifying the following record:

Name of safety director or executive officer:

Title:   Date (mm/dd/yy):

Phone number:      
Email address (required):

Name of company:

Group, department, division or unit covered by this application:

Character of work performed:

Number of employees covered by this application:

These employees make up a s self-contained unit under single supervision.

They worked from:

Month Day Year   ...TO...   Month Day Year

Without a recordable accident as defined in the rules of the award.

Type of award requested (Check one)

Number of consecutive miles: 100,000    250,000    500,000    750,000    1,000,000 Other (indicate below)	Number of Years 5 years    10 years    15 years    20 years    25 years Other (indicate below)

As of the date of this application, this record HAS HAS NOT been broken.

Award Instructions

Do not laminate the award (furnished by SGA - 3-4 weeks delivery)

Laminate the award (Approx $50 - 6-8 weeks delivery)

Please send additional copies of this award ($5 per copy)

Additional copies

Mail Award to:

NAME:
COMPANY:
ADDRESS:
CITY, STATE, ZIP :