Safety Professional Application

Rules & Regulations
1. Nominee’s company must be an IMTA member and the nominee must be a member of the IMTA Safety and Maintenance Council.
2. Any person responsible for supervising truck safety activities is eligible.
3. Previous award winners are ineligible.
4. Judging will be based upon professional achievements, success in advancing highway and industrial safety, relationship and cooperation with government officials, methods of solving safety problems facing the nominee’s fleet.
5. Engagement in state trucking association safety activities and other safety professional organizations are also of high importance.
6. MUST BE ABLE TO ATTEND SMC AWARDS BANQUET

Nominator Information

I certify that the nominee is responsible for supervising safety activities and all statements made in support of this nomination are true. This person is of high moral character and has devoted his or her career to the field of highway and industrial safety.

* Indicates required field

Name *

First

Last

Title *

Company *

Email *

Phone Number *

Nominating Company Address *

Line 1

Line 2

City

State

Zip Code

Country

Nominee Information

Name *

First

Last

Title *

Company *

Date of Birth *

Spouse's Name *

First

Last

Children (names & ages) *

Memberships (church, lodges, clubs, etc.) *

Other Safety Activities *

Walk-up Song (Title & Artist) *

Employment History

Include information regarding the experience, training, activities, recognition, and achievements. Fleet information pertaining to the type of fleet, safety program, and safety records may also be included. Particular emphasis should be placed on the most recent years.

Current Company/Most recent *

Range of Years Employed (20XX-20XX) *

Position/Responsibilities/Accomplishments *

Next Most Recent Employer *

Range of Years Employed *

Position/Responsibilities/Accomplishments *

Third Most Recent Employer *

Range of Years Employed *

Position/Responsibilities/Accomplishments *

Upload Supporting Narrative

The nomination should be supported by information regarding the nominee’s experience, training, activities, recognition, and achievements. Fleet information pertaining to the type of fleet, safety program, and safety records may also be included. Particular emphasis should be placed on the most recent years.

UPLOAD FILE AS A WORD DOCUMENT, NOT A PDF. THE IMTA WILL REMOVE ALL IDENTIFYING INFORMATION FOR EVALUATION BY THE COMMITTEE. WE DO NOT WANT TO RETYPE FROM A PDF. THANK YOU!

Upload File *

Max file size: 20MB

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