Request Consultation Form

REQUEST FOR CONSULTATION SERVICES FORM

The Consultation Section of New Mexico provides no cost consultation services to New Mexico employers upon request. Consultants assist employers in evaluating safety and health programs. Comprehensive consultations visits evaluate all aspects of an employeru2019s safety and health program and provide guidance on incorporating safety and health management into their daily operations.
Your only obligation is a commitment to correcting serious job safety and health hazards in a timely manner. You agree to make a commitment when returning this signed request form along with the last 3 years of your OSHA 300s and 300As.
Please complete the following to request onsite consultation. This information will assist us in evaluating your request. Someone from the Consultation Section may contact you if additional information is needed.

EMPLOYER INFORMATION:
Corporate Name:*
Doing Business as (DBA) or Establishment Name:*
Contact Person*

First

Last
Position / Title:*
Phone*
Fax Number
Cell Phone:
Email*
Site or Physical Address:*

Street Address

Address Line 2

City

New Mexico

ZIP Code
Mailing Address*

Street Address

Address Line 2

City

State

ZIP Code

(If different from site or physical address)
Nature of Business / Brief Description of Business:*
NAICS/SIC Code (If known)
Number of Employees:*
Type of Employer (Select Public or Private secoter Employer)*

Public or Private sector employer
Where did you hear about us?*
FOR APPROVAL BY A COMPANY OFFICER OR SUPERVISOR (MUST BE SIGNED):
Type Name of Officer:*

First

Last
Position / Title*
Date*

MM slash DD slash YYYY
Signature*
FOR APPROVAL BY A COMPANY OFFICER OR SUPERVISOR (MUST BE SIGNED):

Request Consultation Form

REQUEST FOR CONSULTATION SERVICES FORM

EMPLOYER INFORMATION:

FOR APPROVAL BY A COMPANY OFFICER OR SUPERVISOR (MUST BE SIGNED):

FOR APPROVAL BY A COMPANY OFFICER OR SUPERVISOR (MUST BE SIGNED):

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