EC Online Registration Form

Register for Safety Management Services, Inc.’s EC Online below, or print the Registration Form and Fax or Mail it to:

Safety Management Services, Inc.
1500 N. Arlington Heights Road, Suite 1502
Arlington Heights, IL 60004-4827
877-577-6550 Toll Free ** 847-577-6550 Tel ** 847-577-6653 Fax

Facility or Organization  Name
Address
Address
City
State	Zip
Phone #	Ext.
Bed Count
Email Address
Facility Website
Next JCAHO® Survey Date
Name of Master User
Title/Position
Address (if different from above)
Telephone
Fax
Email
Name of User #1
Title/Position
Address (if different from above)
Telephone
Fax
Email
Name of User #2
Title/Position
Address (if different from above)
Telephone
Fax
Email
Name of User #3
Title/Position
Address (if different from above)
Telephone
Fax
Email
Check will follow registration
Purchase order # (Required)
Check included with this mailed registration
Credit Card (please specify)
VISA MasterCard Card #  Expiration: Month Year Name as it appears on card