Print this application, complete and return mail to KSHN.

2009 KSHNF CIRCLE Grant Application

** TYPE or PRINT ALL Information **

Name                                                                                                                Daytime Phone                                                   

            Address                                                                         City                                                                    State _______

Zip                                                         Email   ____________________         

Employer                                                                                                                                    

Use additional paper to provide detailed information for Items 1-5.  TYPE or PRINT ALL information.

1. Which certification are you obtaining?

2. Describe your construction safety experience.

3. Describe how obtaining certification will impact your career.

4. Describe how you will use the certification.

Provide two (2) references familiar with your career.

Name:  _________________________________      Name: _________________________________

Title:                _________________________________      Title:   _________________________________

Address: ________________________________     Address: _______________________________

              ________________________________                    _______________________________

Telephone: ______________________________      Telephone: _____________________________

Email: __________________________________     Email: _________________________________

I declare that all information in this application and submitted in support of this application is true.

Signature:                                                                                              Date:                                      

Mail your completed application to:

Kentucky Safety and Health Network Foundation, Inc.

PO Box 4087

Frankfort KY 40604-4087