- Home
Documents
- “Cousin It” Adams 1313 Mockingbird Way Tulelake, CA 96134
99
“Cousin It” Adams 1313 Mockingbird Way Tulelake, CA 96134
“Cousin It” Adams 1313 Mockingbird Way Tulelake, CA 96134
Embed Size (px)
DESCRIPTION
“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. - PowerPoint PPT Presentation
Citation preview
“Cousin It” Adams
1313 Mockingbird Way
Tulelake, CA 96134
AUTHORIZED PERSONNEL
ONLY
Modoc
Siskiyou
Klamath
Josephine
6/17/82 10/7/05
11/24/05
D.O.B. ______________5/15/1992
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
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
Hello, my ___________
is Dracula.
867-5309
348-3927
REPORT
Name Johnny Bravo
Description of Accident
I fell and broke my arm.
___________________
REPORT ALL ACCIDENTS
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
John DoeX _________________________
SOCIAL SECURITY NUMBER
CA
ORAZ
WA
NM NV
AK
IDVA
WV
NY
MTCO
UT
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
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
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
USE EAR PROCTECTION
WEAR SAFETY
GLASSES
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
20051776
1492
1991 1812
97601
77831
96134