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Umber: ( ) Fax Number: Contact Name: ( ) Email: Title: Construction NAICA Code: Cell No. ( ) Company occupation / Specialty: Average number of employees paid in all pay periods per year: Average number of employees who worked for your Co.: Number of pay periods during the year: Total hours worked by all employees: see over Trades Employed: Average number of supervisors(YR): Do you have a budget for safety? Do you have a safety department? yes no Do you have a safet.

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