Page 1 “Cousin It” Adams 1313 Mockingbird Way Tulelake, CA 96134Page 2 ADDRESSPage 3 Page 4 AGEPage 5 APPLY HEREPage 6 APPLICATIONPage 7 4/xx/xxPage 8 APRILPage 9 8/xx/xxPage 10 AUGUSTPage 11 Page 12 AUTHORIZED PERSONNEL ONLYPage 13 Page 14 CAUTIONPage 15 Page 16 CITYPage 17 Modoc Siskiyou Klamath JosephinePage 18 COUNTYPage 19 Page 20 DANGEROUSPage 21 6/17/82 10/7/05 11/24/05Page 22 DATEPage 23 D.O.B. ______________5/15/1992Page 24 DATE OF BIRTHPage 25 1-5-2006Page 26 DAYPage 27 12/xx/xxPage 28 DECEMBERPage 29 Page 30 EMPLOYEES ONLYPage 31 $ BOSSPage 32 EMPLOYERPage 33 2/xx/xxPage 34 FEBRUARYPage 35 Page 36 FIRSTPage 37 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 28Page 38 FRIDAYPage 39 1/xx/xxPage 40 JANUARYPage 41 7/xx/xxPage 42 JULYPage 43 6/xx/xxPage 44 JUNEPage 45 Page 46 KEEP AREA CLEANPage 47 12-31-2006Page 48 LASTPage 49 3/xx/xxPage 50 MARCHPage 51 5/xx/xxPage 52 MAYPage 53 Page 54 MIDDLEPage 55 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 28Page 56 MONDAYPage 57 Page 58 MONTHPage 59 Hello, my ___________ is Dracula.Page 60 NAMEPage 61 11/xx/xxPage 62 NOVEMBERPage 63 10/xx/xxPage 64 OCTOBERPage 65 867-5309 348-3927Page 66 PHONE NUMBERPage 67 Page 68 PRINTPage 69 REPORT Name Johnny Bravo Description of Accident I fell and broke my arm. ___________________Page 70 REPORT ALL ACCIDENTSPage 71 SAFETY RULESPage 72 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 28Page 73 SATURDAYPage 74 9/xx/xxPage 75 SEPTEMBERPage 76 John DoeX _________________________Page 77 SIGNATUREPage 78 123-45-6789Page 79 SOCIAL SECURITY NUMBERPage 80 CA ORAZ WA NM NV AK IDVA WV NY MTCO UTPage 81 STATEPage 82 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 28Page 83 SUNDAYPage 84 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 28Page 85 THURSDAYPage 86 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 28Page 87 TUESDAYPage 88 Page 89 USE EAR PROCTECTIONPage 90 Page 91 WATCH FOR TRUCKSPage 92 Page 93 WEAR SAFETY GLASSESPage 94 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 28Page 95 WEDNESDAYPage 96 20051776 1492 1991 1812Page 97 YEARPage 98 97601 77831 96134Page 99 ZIP CODE