Michigan Challenge Program

If you want to participate in the Michigan Challenge Program, please complete this form.

If you have no information to enter in a section, please enter N/A.

*Date of Application

*FEIN

*NAICS

Applicant's Name & Address Information

*Company/Corporate Name

*Company/Corporate Street Address

*Company City

*Company Zip Code

*Company County

*Site Manager's Name

*Site Manager's Title

*Site Address (if different from above)

Applicant’s Contact Information

*Applicant's Contact Name

*Applicant's Contact Title

*Applicant's Contact Phone Number

*Applicant’s Contact Email Address

Collective Bargaining Representative

*Union Name and Local #

*Representative Name

*Representative Street Address

*Representative City

*Representative Zip Code

*Representative County

*Representative Phone Number

*Representative Email Address

Employees

*Number of Employees

*Number of Contract Employees

Injury & Illness Rates Information

Current Year

*Current Year

*Total Hours Worked

*TCIR

MI OSHA

*DART

MI OSHA

*Previous Year

*Total Hours Worked

*TCIR

MI OSHA

*DART

MI OSHA

Optional Information

Exceptions may be made for a company newly established. Please respond here, if applicable. Please provide details.

Exceptions may be made when the employer has installed a new equipment /process, etc. Please respond here, if applicable. Please provide details.

Exception may be made to a company recently reorganized with new management or supervision and does not have an effective SHMS in place. Please respond here, if applicable. Please provide details.

Describe nature of business operations

*Briefly state the nature of your business operations

Applicant’s Commitment Statement and Signature

File upload

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Applicant's Name & Address Information

Applicant’s Contact Information

Collective Bargaining Representative

Employees

Injury & Illness Rates Information

Optional Information

Describe nature of business operations

Applicant’s Commitment Statement and Signature