Dl Form 1-65 - Emergency Information - Us Department Of Labor
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1US Department of Labor
Emergency Information
We need to know who to contact in case of an emergency
Instructions -please print or type the requested information.
Complete Employee Information section
-
Provide name, address and phone number for two emergency contacts Under Contact Information.
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Sign the completed form and turn it in to your supervisor.
-
- Complete a new form when any of the information provided becomes obsolete.
The personnel office will keep the original and send a copy to your supervisor.
Employee Information
-
-
Employee Name:
Organization:
Work Location or
Title and
Grade:
Room Number:
Home Street
Address:
City, State, Zip
Code:
city:
state:
zip:
Home Phone:
Work Phone:
ext
ext
Contact Information
1
Name of Contact
Relationship to
Employee:
First Name
M.I.
Last Name
City
Zip Code
Street Address:
State
Work Phone
Home Phone
ext
2
Name of Contact
Relationship to
Employee:
First Name
M.I.
Last Name
City
State
Zip Code
Street Address:
Home Phone
Work Phone
ext
Signature of Employee
Date
DL Form 1-65
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Parent category: Legal