MIOSHA Advisory Committee Application

*Full Applicant Name

*Street Address

*City

*State

*Zip Code

*Phone Number

*Applicant Email Address

*Present Employer

*Business Street Address

*City

*State

*Zip Code

*Business Phone Number

Business Fax Number

*Business Email Address

*Name the MIOSHA Advisory Committee(s) or rule set that you are interested in serving on

*List your areas of expertise in regards to the above subject matter

*Who do you represent? (Select One) Labor Management Technical Advisor

*Is your employer aware of this application? Yes No

*Does your employer support your participation? Yes No

*Are you a registered lobbyist: Yes No

*Will you benefit from financial gain if you are appointed to a committee: Yes No

*Include letter(s) of endorsement, if applicable. Reason for applying for this committee:

Letter of Endorsement Upload

*Please attach a resume of your work history or areas of expertise or interest in safety and health concerns for the advisory committee(s) you are applying for.

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Standard Advisory Committee Application