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:
Company 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 on Site:*
Number of Employees Company-Wide:*
Type of Employer (Select Local Government or Private Sector Employer)*
Where did you hear about us?*
Union Representation
Union Representative Name

First

Last
Phone
Email
Union Name
Local:
For approval by a company officer or superviser (Must be signed)
Type Name of Officer:*

First

Last
Position / Title*
Date*

MM slash DD slash YYYY
Signature*

Request Consultation Form

REQUEST FOR CONSULTATION SERVICES FORM

EMPLOYER INFORMATION:

Union Representation

For approval by a company officer or superviser (Must be signed)

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