Select the Highway Safety Day date and location for which you would like to register.  If you need to register for an additional location, you will need to submit another registration form and will prompted at the end of the registration process. *


 
What is the name of your county/municipality?

 
To whom should we send Highway Safety Day correspondence, audiometric test results, and MSHA certification sheets?

 
Please provide a phone number for the contact listed above.

 
Is this contact listed above the Highway Commissioner/Director of Public Works?

     
 
Please provide the name of the Highway Commissioner/Director of Public Works

 
Please provide a phone number for the Highway Commissioner/Director of Public Works

 
How many attendees would you like to register?

You will be asked to provide the full names of each attendee to properly generate MSHA certification cards.
 
Will all attendees take part in annual audiogram testing?

     
 
How many will take part in annual audiogram testing?

 
Please provide the full name of each attendee.  Please ensure correct spelling - your entries will be used on attendee MSHA cards.  Approximately 30 days prior to the Highway Safety Day you will receive an list containing each attendee you've registered

When complete, please scroll down to submit this registration.
 
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Thank you, {{answer_40055982}} for registering for the 2017 Highway Safety Days!  You've registered for the following date and location {{answer_23396765}}.  We look forward to seeing you and your employees!

If you need to make changes to this registration, please contact Jodi Traas at 800.511.9797.
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