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Employee Emergency Contact Form Arkansas Secretary of

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Employee Emergency Contact Form Arkansas Secretary of Powered By Docstoc
					           Arkansas Secretary of State
           Employee Emergency Contact Form

HR Personnel Only

New Hire                                           Change/Update


Please complete the information below:

Employee Information

       Employee Name __________________________________________________________________
                      (Last)                    (First)               (Middle)
       Department ______________________ Birth Date _______________________

       Veteran/ _____Yes_____No________         Smoker/_____Yes_____ No_________

Personal Contact Information

       Home Address ____________________________________________________________________

       City, State, ZIP _________________________________________County of Residence___________

       Home Telephone ___________________________ Personal Cell Phone_______________________

Emergency Contact Information
       In case of an emergency, please list a relative and/or friend we may contact.
       First Choice-

       (1) Name ____________________________ Relationship_______________________

       Address ____________________________________________________________

       City, State, ZIP _______________________________________________________

       Home Telephone ______________________Cell Phone______________________

       Work Telephone ______________________Employer_______________________

       Second Choice (If unable to contact first choice)-

       (2) Name ____________________________ Relationship_______________________

       Address ____________________________________________________________

       City, State, ZIP _______________________________________________________

       Home Telephone ______________________Cell Phone______________________

       Work Telephone ______________________Employer_______________________


1                                                                                             5-2010
Medical Information

         Please list any medications and/or other substances you are allergic to (ex: penicillin, food, insects, etc.):




         Please list any medical conditions emergency personnel should be aware of (ex: diabetes, asthma,
         seizures, etc.):




         Physician’s Name________________________________Phone_________________________

         Dentist’s Name__________________________________Phone_________________________

         Hospital Of Choice_______________________________(EMT or Paramedic may override choice)

Please read before signing form:

I understand that it is my responsibility to keep this information current. I will promptly report any changes to the
Human Resource Department.

I understand this information will be retained in the Human Resource Office and will remain confidential.

I certify that I have voluntarily provided the above contact information and authorize the Arkansas Secretary of
State and its representatives to contact any of the above reference(s) and/or physician(s) on my behalf in the
event of an emergency.

________________________________________                        _________________________________
Employee Signature                                               Date

________________________________________                         _________________________________
Human Resource Staff                                             Date Processed




2                                                                                                                5-2010

				
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