CERTIFICATE OF COMPLETION
Company name: Address: City/state/ZIP: I hereby certify that the conditions and requirements outlined in the Safety Grant Agreement have been fulfilled by the company named above. Receipts and proof of payment for items purchased, and photographs of new or modified equipment and items, are enclosed. I further certify that I am a valid representative of the company named above and am authorized to certify project completion by the owner or a corporate officer of the company. I understand that in accordance with the Safety Grant Agreement, documentation of project completion must be submitted to the Minnesota Department of Labor and Industry prior to the release of grant monies.
Authorized signature
Date
Title
Project completion date
Complete and return this certificate and all related documentation to the Minnesota Department of Labor and Industry, Workplace Safety Consultation, 443 Lafayette Road N., St. Paul, MN 55155. Contact Jim Collins at (651) 284-5060 if you have any questions. Project approved for payment
James Collins, OMT Director Workplace Safety Consultation
Date
FOR OFFICE USE ONLY
Approved for $ Project disapproved for payment
Date AC Signed Date to acct CFMS #
James Collins, OMT Director Workplace Safety Consultation
Revised 03/09
Vendor # Agreement #