2016 AFS MILLIONAIRES SAFETY AWARD APPLICATION

2016 AFS MILLIONAIRES SAFETY AWARD APPLICATION This award recognizes facilities at a single location that reached 1 million, 2 million, 3 million or any other million increment of consecutive man-hours worked without incurring an occupational injury or illness that resulted in days away from work or death during the period Jan. 1 through Dec. 31, 2016. Open to AFS Corporate Members only. Note: Reaching the million hour increment does not mean all hours were accumulated in 2016. But rather at some date in 2016 the facility attained the milestone. The start date could have been months, or for smaller facilities, year(s) before achieving the million hour record in calendar year 2016. This entry must be submitted no later than Friday, Jan. 20, 2017. Only AFS Corporate Members are eligible to enter. This recognition is based on a member company achieving one of the increments listed above in calendar year 2016. The awards will be presented at AFS’s 121st Metalcasting Congress, April 25- 27, 2017, in Milwaukee. If you have any questions, please call 800-537-4237. SECTION 1: (Please Print)

Organization name: (Name that will appear on plaque)

Award Facility Location:

NAICS/SIC:

Type of product(s) made:

Number of Employees:

Company Contact:

Title:

Address: City:

State:

Phone:

Email:

Million hour increment of SECTION 2: Information Verification

Zip:

Hrs was achieved on (Signed & Dated by Company Officer)

I certify the above information is correct and we are AFS CORPORATE MEMBERS: Print name:

Signature:

Title:

Date: Email to: [email protected] MAIL OR FAX COMPLETED FORM TO AFS – FAX 847-824-7848 ATTN: Pam Lassila TO ARRIVE NO LATER THAN Friday, Jan. 20, 2017

, 2016