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*Indicates required fields

* 1. Account Type
Business     Personal
* 2. Name
* 3. Company name
* 4. Company mailing address Address


City

State
Zip
* 5. Email address (business)
6. Phone number (business)
* 7. Approximate number of employees at your location
* 8. What are your areas of interest?
Emergency planning
Emergency training & preparedness
Emergency equipment & supplies
First aid kit maintenance services
Multi-site supply or training programs
* 9. How did you hear of SafetyMax? Internet
Promotional mailing
Email promotion
Friend/Associate
Other  


Please tell us about your company (optional)
10. Does your company have an emergency response team? Yes    No
11. What type of emergency training does your current program include? General Emergency Preparedness
CPR
First Aid
Emergency Equipment
AED (Defibrillator)
Building Evacuation
Home Emergency Preparedness
None
Other
12. How does your company currently replenish its first aid supplies? Maintained by outside vendor
Maintained by employee
Not currently maintained
13. If maintained by outside vendor, name of vendor
14. Name of decision maker (manager) for these services
15. Would you like a SafetyMax consultant to contact you?
   

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Sincerely,
The SafetyMax Team
(800) 585-8506
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