Each entry must include answers to the following:

____Yes ____No This department was cited for EPA (Environmental Protection Agency) violations from Jan. 1, 2007, to Aug. 31, 2008.

____Yes ____No This department was cited for OSHA (Occupational Safety and Health Administration) violations from Jan. 1, 2007, to Aug. 31, 2008.

____Yes ____No This department was cited for ADA (Americans with Disabilities Act) violations from Jan. 1, 2007, to Aug. 31, 2008

____Yes ____No This department was cited for EOEC (Equal Opportunity Employment Commission) violations from Jan. 1, 2007, to Aug. 31, 2008.

CONTACT INFORMATION

Name of Department _______________________________

Name of Submitter _______________________________

Title  _______________________________

Email _______________________________

Phone _______________________________

Name of Director _______________________________

Title _______________________________

Email _______________________________

Phone _______________________________

Department Address _______________________________

Address 2 _______________________________

City _______________________________

State _______________________________

Zip _______________________________

General Phone _______________________________

Fax _______________________________

This entry must be signed by the department's elected official, such as the mayor or county board director.

Elected official's statement: To the best of my knowledge, this entry, which includes all data and information submitted as a part of it, is true and correct, and the department is eligible for this competition. 

Name ____________________________

Signature _______________________________

Date (mmddyy) ____________________________

Title _______________________________

Email _______________________________

Phone _______________________________