Receipt and Acknowledgement

							                                                     -14-



                                     ACKNOWLEDGEMENT OF RECEIPT

                                     SAFETY TIPS AND RIGHT TO KNOW


Employee:

I, the undersigned, hereby certify that I have received and read the booklet, Safety Tips and Right to
Know. I further understand that willfully neglecting the safety measures could lead to discipline.

Please check appropriate box:

      Full-Time Academic

      Full-Time Classified

      Part-Time Academic (includes part-time instructors, part-time counselors, librarians, or hourly academic substitutes)

      Part-Time Classified (i.e., work study, student worker, short term, classified substitutes and hire-a-youth)


Department

                                     Grossmont            Cuyamaca               District


  Print Name
                              Last                                First                                   MI


Social Security #         -     -

Signed

Dated



        RETURN WITH HIRE PACKET TO THE GROSSMONT-CUYAMACA COMMUNITY
              COLLEGE DISTRICT EMPLOYMENT SERVICES DEPARTMENT




District Employment Services Use Only

      Transposed to Insight; use LicnCert code “SK”              By: __________ (initials) Date:_____________

02-0153-014W (09/04/bg)