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“Cousin It” Adams
1313 Mockingbird Way
Tulelake, CA 96134
ADDRESS
AGE
APPLY HERE
APPLICATION
4/xx/xx
APRIL
8/xx/xx
AUGUST
AUTHORIZED PERSONNEL
ONLY
CAUTION
CITY
Modoc
Siskiyou
Klamath
Josephine
COUNTY
DANGEROUS
6/17/82 10/7/05
11/24/05
DATE
D.O.B. ______________5/15/1992
DATE OF BIRTH
1-5-2006
DAY
12/xx/xx
DECEMBER
EMPLOYEES ONLY
$
BOSS
EMPLOYER
2/xx/xx
FEBRUARY
FIRST
S M T W T F S
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 23 25 26 27 28
FRIDAY
1/xx/xx
JANUARY
7/xx/xx
JULY
6/xx/xx
JUNE
KEEP AREA CLEAN
12-31-2006
LAST
3/xx/xx
MARCH
5/xx/xx
MAY
MIDDLE
MONDAY
MONTH
Hello, my ___________
is Dracula.
NAME
11/xx/xx
NOVEMBER
10/xx/xx
OCTOBER
867-5309
348-3927
PHONE NUMBER
PRINT
REPORT
Name Johnny Bravo
Description of Accident
I fell and broke my arm.
___________________
REPORT ALL ACCIDENTS
SAFETY RULES
SATURDAY
9/xx/xx
SEPTEMBER
John DoeX _________________________
SIGNATURE
123-45-6789
SOCIAL SECURITY NUMBER
CA
ORAZ
WA
NM NV
AK
IDVA
WV
NY
MTCO
UT
STATE
SUNDAY
THURSDAY
TUESDAY
USE EAR PROCTECTION
WATCH FOR TRUCKS
WEAR SAFETY
GLASSES
WEDNESDAY
20051776
1492
1991 1812
YEAR
97601
77831
96134
ZIP CODE
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