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<br />Instructiona:
<br />Please type or prini clearly. All employers must complete 5ections I, II, III and the attached W-9. Thanl<s for your interest in providing a sa{e
<br />workplace for your employees.
<br />To ensure BWC has the necessary information to quickly issue a safety yrant check to you, please complete the attached W-9 form. The
<br />W-9 will allow us to add your company to the state accounting system aneJ provide tax information in case we must issue a 1099 form.
<br />Employers must verify how tlre grant money was spent by Dec. 31. Any funds not used or not verified to BWC may be subject to a 1099 form.
<br />Acceptable verification is the employer's original paitl invoice and copies of cancelied checkls). If the employer fails to provide this documentation,
<br />a 1099 may be issued.
<br />SeCtio?1 L' Employer information
<br />Name of empioyer City of North Olmsted _
<br />Doiny business as (DBA) name
<br />Address 5200 D
<br />City North Olmsted State OH ZIP Code 44070 _
<br />County Cuyahoga
<br />Employer BWC policy number 3_ 1_ 8_. 0! 68, O 2 I Fetleral tax ID num6er 3 46` 0 0,.2 ` 0 4, 8
<br />Employer contact name Cheryl Farver
<br />Title Director of Human Resources
<br />Telephone number 1' 41, 4; 0 T
<br />4 1 V;6. 1_ 4,;,1 1 7_11 _ 31 Ext Ti r i -
<br />Fax num6er r4 4 i_0J 7, 7 i;_7 3 ? 113!! 2
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<br />E-tT181l eddfeSS f.i a.,,'I' ` V i e,j r... ._C Cd ?? Il O ? Y'. t.J? .rlT_....????O.E ?.V?[Il. 1.S -.;t.`ze..i?d?l ,. ;iC ' O E M.. : Section I1: Application for drug-free workplace
<br /> education antl training grant
<br />To apply for a drug-free workplace safety grant, you are required to participate in BWC's DFWP or DF-EZ, or a comparable program. Employers
<br />with a comparable program are only eligible for funding to cover employee education, supervisor training and associatetl materials. If you
<br />are not participatiny in BWC's DFWP or DF-EZ, submit proof of your comparable program, alony with this safety grant application, agreement
<br />antl a completed W-9. Proof of comparability includes a written policy that inclutles requirements for annual employee education and supervisor
<br />training, drug and alcoliol testing, and employee assistance. If you would like more information on BWC's DFWP or DF-EZ, or if you would
<br />like to enroll, please call 1-800-OHIOBWC antl press 2, or access our Web site, ohiobwc.com.
<br />Name of campany providing training Concern
<br />Adtlress 6000 West Creek Road, Suite 20 _
<br />City Independence
<br />State OH ZIP code 44131
<br />ou are a private employer
<br />lfyou are a`pub?tc employer
<br />The DFWP and DF-EZ
<br />safety grant requires
<br />a' 1, 870. 0 cornpanies providing
<br />education and traininy
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<br />?1,402.5 to have active workers'
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<br />?' compensation coveraye.
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<br />li you do not participate in BWC s DFWP or DF-EZ, please submit, alony with the application, proof of your compara6le drug-free worlcplace
<br />program antl attach your current written policy. Remem6er to include information on the compara6le proyram elements listed aboue.
<br />e«?._?n,.„?f•: :. ? .? . a,. ?n,?,,????.:.,«.?.-„ ?.??,? ?, .N.?.,. ?a ?, ??,.a ?:; ._?<. ?
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