2014 Safety Recognition Program Order Form
Name:
Employee #: ______________________
(please print)
Address:
Date: ________________
Phone #: ______________________________
(NO P.O. BOXES)
Qty.
(where you can be contacted regarding this order)
Item Description
Pts
(mark how many of each
color, if applicable)
Color/Selection
Size (circle)
HATS
Ball Cap - structured
1
Black
One Size (plastic adjuster back)
Ball Cap - unstructured
1
Black
One Size (fabric adjuster buckle back)
Flame Orange/Camo Hat - structured
1
Orange w/partial camo on bill
One Size (fabric adjuster buckle back)
Wax Wear/Oil Cloth Hat - unstructured
2
Dark Brown
One Size (fabric adjuster buckle back)
Winter Hat (beanie)
1
____ Orange ____ Black
One Size (100% acrylic)
Winter Hat Fleece Camo (beanie)
1
Camo
One Size (fleece)
Full-brim Hard Hat *
2
____ Orange
One Size
1
____ Orange ____ Safety Yellow
S M
L XL 2X
3X 4X 5X
T-shirt – long sleeve, basic
1
____ Orange ____ Safety Yellow
S M
L XL 2X
3X 4X 5X
T-shirt – long sleeve, logo on sleeve
2
____ Black ____ Orange ____ Gray
S M
L XL 2X
3X 4X 5X
Golf Shirt – short sleeve (men’s or ladies’ sizes)
3
____ Black ____ Orange ____ White
S M L XL 2X 3X 4X 5X 6X
Nike Dri Fit Golf Shirt (men’s or ladies’ sizes)
5
____ Black/White ____ White/Blacl
S
M
L
Reflective Mesh T-Shirt* (each)
2
Yellow w/reflective tape
M
L
XL
Denim Shirt – long sleeve (men’s or ladies’ sizes)
4
Prewashed denim blue
S M
Crewneck Sweatshirt
3
____Orange ____ Black ____ Yellow
S
4pt: S M L XL 5pt:2X 3X 4X 5X
APPAREL
T-shirt – short sleeve:
Pocket
No Pocket
Hooded Pullover Sweatshirt
4-5
____ Safety Yellow
Hooded Zip-up Sweatshirt
4-5
____ Orange
Hooded Zip-up Sweatshirt - with reflective tape
5
Sport Teck ¼ Zip Sweatshirt
4-5
Pullover Microfiber Windshirt
____ Black
____ Black
____ Safety Yellow
XL
2X
2X
3X
L XL 2X
M
L
XL
3X 4X
3X 4X 5X
2X
3X
4X
4pt: S M L XL 5pt:2X 3X 4X 5X
____ Orange
S M
L XL 2X
3X 4X 5X
____Black ____ Dk. Gray ____ Lt. Gray
4pt: S M L XL 5pt:2X 3X 4X 5X
3
Black
S
Weatherproof Lite Bomber Jacket
5
Safety Yellow
5-in-1 Bomber Jacket
Parka Style Bomber Jacket
7
8
Carhartt Jacket
12
Safety Yellow
Safety Yellow
____ Brown
M
M
M
____ Black
Carhartt Bibs
14
____ Brown
____ Black
$10.00 Gift Card * (Allow 2-3 weeks for processing.)
1
_____ Sears
_____ Wal-Mart
Chrome/Stainless Travel Mug
2
Black Chrome & Stainless
Tervis Tumbler 24 oz.
2
Clear with Orange Lid
Tervis Water Bottle 24 oz.
2
Clear with Grey Lid
Lunch Tote
2
Orange & Black Thermal Tote
Folding Nylon Big Boy Chair (w/storage bag)
5
Black – orange logo on back
Grease Gun - 2 Speed *
24
Lincoln Lube 18V Cordless PowerLuber, Includes Charger, (2) 18v Batteries & Case.
M
L
XL
2X
3X
4X
L
XL 2X 3X 4X 5X
L XL 2X 3X 4X 5X 6X
L
XL 2X 3X 4X 5X
Order by Chest Size _________
Waist ______(min. 32”) Inseam Length ______
OTHER
_____ Lowe’s
_____ Cabelas
Oversized, holds up to 350 pounds
Send completed form to: Kokosing Construction Company, Inc., Attn: Human Resources – Teri Parker, P.O. Box 226, Fredericktown, OH 43019
Notes: Make sure you are ordering the correct size. We are unable to accept returns. Please allow 2 weeks for shipment of your order (4 weeks for
Carhartts).Copies of this form and descriptions of items are available at www.kokosing.biz
Revised 4/16/14
* All items have Kokosing Company logo except those marked with asterisk.