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Drug-Free 1 1 . ' P 1 1 . . ' ? ANT$ A1 i . t <br />Instructions: <br />Please type or print clearly. All employers must complete Sections (, II, III, the attachetl W-9 antl the Vendor Information Form. Thanks for <br />your interest in providing a safe 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 and Vendor <br />Inforrnation forms. Both the W-9 antl Vendor Information Form will allow us to add your company to the state accounting system z3nd provide <br />tax information in case we must issue a 1099 form. Employers must verify how the grant money was spent by Dec. 31. Any funds not used <br />or not verified to BWC may be subject to a 1099 form. Acceptable verification is the employer's oriyinal paid invoice and copies of cancelled <br />clieck(s). If the employer fails to provide this docurnentation, a 1099 may be issued. <br />Section L' Employer information <br />Name oi employer City of North Olmsted _ <br />Doing business as (DBA) name _ <br />Address 5200 Dover Center Road <br />City Nort-h°flimsted state Ohio ZIP Code 44010 <br />County Cuvahoga _ <br />Empfoyer BWC policy number 3, 1, 8 016 80 , 2_ Federal tax ID number 3 4;!6 0;0 2; 0'4 8 <br />Employer contact name Cheryl Farver <br />Title Director of Human Resources <br />Telephone number 4 4 0, Z_ 1`_6_ ?4 ??_1 ' 7± 3,' Ext. <br />Fax number 0' 71 _ 7 4.',_3 ;3 .'; 2; <br />,.... .... . 1,.. . . ... <br />-.,-... ;. "..._ ...... i ..__ ._. . . <br />E-mail address f_ a,r , v; e..r ' c{@ _:.n ?o__ tih - 0 1 m;s ' t e!d . c o' m <br />SeCtion 11: Application for drug-free workplace education and training grant <br />To aaply for a druy-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 trairiing and associated materials. If you <br />are not participating in BWC's DFWP or DF-EZ, submit proof of your comparable program, along with this safety grant application, agreement <br />and a completed W-9. Proof of comparability includes a written policythat includes requirements for annual employee education and supervisor <br />training, drug and alcohol 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 and press 2, or access our Web site, ohiobwc.corra. <br />Name of company providing training ConCern <br />Address 6000 West Creek Road, Suite 20 <br />City Independence _ <br />State OH ZIP code 44131 <br />ou are a private emplo <br />yer <br />ou a,r!e aspu?lwemployer <br />The DFWP and DF-EZ <br />?'?' `}?« 1, 800. 0 safety grant requires <br />1it companies providing <br />7,1 <br />education and training <br />:?? "?`+ 1, 350.0 to have active workers' <br />compensalion coverage. <br />Tiiu , shouldmot •d"S ?? Tlie ? ould ncit exceed $1 biffl <br />,?• ? ? <br />fura,privateern <br />It you do not participate in BWC's DFWP or DF-EZ, please submit, along with the application, proof of your comparable drug-iree workplace <br />? program and atlaoh your current written policy. Rememberto include information on the comparable program elements listed above. <br />?XFF? 8 i j 4 <br />?Oc& -tc7i