EMPLOYEE EMERGENCY CONTACT FORM

Name ______________________________________________________________________________
SS#
__________________________________________________________________________
Personal Contact Info:
Home Address________________________________________________________________________
City, State, ZIP _______________________________________________________________________
Home Telephone # ____________________________ Cell # __________________________________
Emergency Contact Info:
(1) Name_______________________________________Relationship___________________________
Address _____________________________________________________________________________
City, State, ZIP _______________________________________________________________________
Home Telephone # ____________________________ Cell # __________________________________
Work Telephone # _______________________________ Employer _____________________________
(2) Name_______________________________________Relationship___________________________
Address _____________________________________________________________________________
City, State, ZIP _______________________________________________________________________
Home Telephone # ____________________________ Cell # __________________________________
Work Telephone # _______________________________ Employer _____________________________
I have voluntarily provided the above contact information and authorize Grand Forks County and its
representatives to contact any of the above on my behalf in the event of an emergency.
I choose not to furnish any emergency contact information to Grand Forks County at this time.
Employee Signature __________________________ Date __________________________________

0.4:39.7574./0/90..3/.3/98 705708039.3/4784:39..439.931472.-4.943.9..0894.  .0.34190.0432-0.03941.-4.:94707.9.13900.3020703..439.

Sign up to vote on this title
UsefulNot useful