“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

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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

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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

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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

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THURSDAY

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TUESDAY

USE EAR PROCTECTION

WATCH FOR TRUCKS

WEAR SAFETY

GLASSES

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WEDNESDAY

20051776

1492

1991 1812

YEAR

97601

77831

96134

ZIP CODE