Subcontractor Application Company Information Business Name (required) Address (required) Postal Code Mailing Address Phone Cell Phone Fax Email Owner's Name Number Of Business Under Present Company Name Make Cheques Payabal To Cheques to be Mailed YesNo If No Picked up by?: WCB# ***WCB Clearance Letter Must be Sent (Faxed) by WCB Prior to Release of Cheque. WCB Industry Code# GST# Insurance Company Police# Expiry Date 010203040506070809101112 200920102011201220132014201520162017201820192020202120222023202420252026202720282029 Vehicle Information Your Company Unit # Make Model Year Tare Weight License Plate Certificate Date Serial Number Do you have a positive air shut off installed in your unit? YesNo Trailer #1 Information Make Serial Number Year License Plate Certificate Date Trailer #2 Information Make Serial Number Year License Plate Certificate Date Trailer #3 Information Make Serial Number Year License Plate Certificate Date Safety Information Safety Representative's Name Phone# Cell# Fax# Does your company have a basic safety program YesNo Number of lost time incidents (LTI) in last 3 years? A los time incident is one of where the subcontractor/ Driver is away from work for 1 or more days Number of medical aid incidents(MA)in last 3 years? A medical aid is the subcontractor/ Driver needs medical attention from hospital facility Number of fatal injuries in the last 3 years? a fatal injury is when someone dies as a result of the incident / accident Have you ever received a stop work citation from OH $ S? YesNo What is the last inspection date on your fire extinguishers(s)? What size (OH& S#) of first aid kit do you have in your unit(s) Company References Company Name Phone Number Fax Number Contact Name Company Name Phone Number Fax Number Contact Name Company Name Phone Number Fax Number Contact Name Required Reading Ab 1223209 Ltd. REQUIRES THE FOLLOWING : 1. IT IS MANDATORY FOR ALL SUBCONTRACTORS TO BE ORIENTATED TO AND COMPLY WITH Ab 1223209 Ltd. SAFETY PROGRAM, AS WELL AS ORIENTATE TO COMPANY SPECIFIC SAFETY PROGRAMS AS REQUIRED. 2. FIRE RETARDANT COVERALLS, SAFETY GLASSES, HARD HAT AND A SAFETY VEST MUST BE WORN WHEN OUTSIDE YOUR VEHICLE OR PIECE OF EQUIPMENT ON ANY OILFIELD LEASE, LEASE ROAD OR PLANT SITE, OR OTHERWISE POSTED. 3. A MINIMUM OF AN ALBERTA #1 FIRST AID KIT, FLARE KIT AND 5LB FIRE EXTINGUISHER MUST BE PRESENT AND/OR SECURED IN YOUR VEHICLE OR ON YOUR EQUIPMENT AT ALL TIMES. 4. SPEEDING IS ABSOLUTELY PROHIBITED. ALL POSTED SPEED LIMITS MUST BE OBEYED. 5. SMOKING IS NOT PERMITTED ON ANY LEASE OR PLANT SITE. 6. ALL VEHICLES MUST CARRY A GARBAGE BAG. LITTERING IS NOT PERMITTED ANYWHERE. ALL SUBCONTRACTORS AND THEIR EMPLOYEES ARE SUBJECT TO THESE CONDITIONS. PERIODIC INSPECTIONS WILL ENSURE THESE REQUIREMENTS ARE MET AND IMMEDIATE SUSPENSION WILL RESULT IF THEY ARE NOT. THE LENGTH OF SUSPENSION WILL BE DETERMINED BY MANAGEMENT. ALL INCIDENTS MUST BE REPORTED THAT OCCUR ON ANY LOCATION UNDER THE DIRECT OR INDIRECT SUPERVISION OF Ab 1223209 Ltd. THE INCIDENT WILL THEN BE REVIEWED BY MANAGEMENT AND POSSIBLY THE AFFECTED OIL COMPANY. APPROPRIATE ACTION WILL BE TAKEN TO RESOLVE THE ISSUE TO WHATEVER DEGREE AGREED UPON BY BOTH PARTIES. BY CLICKING SUBMIT I AGREE TO THE TERMS AND CONDITIONS AS OUTLINED BY Ab 1223209 Ltd.