“cousin it” adams 1313 mockingbird way tulelake, ca 96134
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“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
D.O.B. ______________5/15/1992
DATE OF BIRTH
1-5-2006
DAY
12/xx/xx
DECEMBER
EMPLOYEES ONLY
$
BOSS
EMPLOYER
2/xx/xx
FEBRUARY
FIRST
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
FRIDAY
1/xx/xx
JANUARY
7/xx/xx
JULY
6/xx/xx
JUNE
KEEP AREA CLEAN
12-31-2006
LAST
3/xx/xx
MARCH
5/xx/xx
MAY
MIDDLE
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
MONDAY
MONTH
Hello, my ___________
is Dracula.
NAME
11/xx/xx
NOVEMBER
10/xx/xx
OCTOBER
867-5309
348-3927
PHONE NUMBER
REPORT
Name Johnny Bravo
Description of Accident
I fell and broke my arm.
___________________
REPORT ALL ACCIDENTS
SAFETY RULES
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
SATURDAY
9/xx/xx
SEPTEMBER
John DoeX _________________________
SIGNATURE
123-45-6789
SOCIAL SECURITY NUMBER
CA
ORAZ
WA
NM NV
AK
IDVA
WV
NY
MTCO
UT
STATE
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
SUNDAY
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
THURSDAY
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
TUESDAY
USE EAR PROCTECTION
WATCH FOR TRUCKS
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
WEDNESDAY
20051776
1492
1991 1812
YEAR
97601
77831
96134
ZIP CODE
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