New York Farm Safety Award Application Farm Name * Farm Owner * First Name Last Name Address of Farm * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Type of Farm * Number of Employees * Farm Offers: * Check all that apply. Safety committee Incentive/motivation program Employee wellness program Formal training/mentoring program Safety inspection program Hazard correction program What is your farm's policy/philosophy regarding safety? * Please provide an example of your management's commitment to safety (please also provide key elements of your safety and health program): * Please provide 2 examples of ways your employees are encouraged to participate in the safety process: * Contact Information of Person Nominating * First Name Last Name Email Title Thank you!
