On-Site Consultation Request Form

Please complete the information below to request a free On-Site Consultation Visit.

Request Type

Employer Legal Name

DBA Name(If applicable)

Business or Site Address

City

State

ZIP Code

Mailing AddressIf different from Business Address

Mailing City

Mailing State

Mailing ZIP Code

Total Number of Employees

Type of Work

Legal Establishment Type

Employer Has Union Employees

Employer Contact Name

Employer Contact Title

Employer Contact E-Mail

Employer Contact Phone

Reason For RequestIn order to better serve you, please select the area of interest that applies

The employer had an OSHA/IDOL inspection in the past 12 months.

If Yes to OSHA/IDOL inspection, Status of Citation?

How did you hear about our services?

Other Comments

524 South 2nd Street, Suite 400
Springfield, IL 62701

800-972-4216

800-785-6055 TTY

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