EMPLOYEE EMERGENCY INFORMATION FORM

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					     EMPLOYEE EMERGENCY INFORMATION FORM
                 (Please print legibly and provide all information requested)


Employee Name: _______________________________________________
                Last                  First                 MI

Team: ________________________ Emplid # (if available) __ __ __ __ __ __ __ __

1st) Person to notify in an emergency:            2nd) Person to notify in an emergency:


___________________________________               ___________________________________
First Name                                        First Name

___________________________________               ___________________________________
Last Name                                         Last Name

___________________________________               ___________________________________
Phone                                             Phone

___________________________________               ___________________________________
Alt Phone                                         Alt Phone

___________________________________               ___________________________________
Address                                           Address

___________________________________               ___________________________________

___________________________________               ___________________________________



If your emergency information changes, complete a new Employee Emergency
Information Form (see link below) as soon as possible and send it to the Library’s Human
Resources and Organizational Effectiveness Team in the Main Library, Room A302.

              http://intranet.library.arizona.edu/teams/hroe/forms.html

My signature affirms that I give my permission for individuals listed on this emergency
contact form to be contacted in the event that an emergency arises requiring
communication regarding my well-being.


Employee Signature:_________________________________________

Date:______________________

				
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