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ADDRESS
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“Cousin It” Adams 1313 Mockingbird Way Tulelake, CA
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AGE
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14 years old Age ______ 16 years old
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APPLICATION
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APPLY HERE
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APRIL
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4/xx/xx
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AUGUST
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8/xx/xx
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AUTHORIZED PERSONNEL ONLY
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CAUTION
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CITY
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COUNTY
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Modoc Siskiyou Klamath Josephine
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DANGEROUS
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DATE
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6/17/82 10/7/05 11/24/05
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DATE OF BIRTH
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D.O.B. ______________ 5/15/1992
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DAY
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DECEMBER
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12/xx/xx
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EMPLOYEES ONLY
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EMPLOYER
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$ BOSS
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FEBRUARY
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2/xx/xx
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FIRST
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FRIDAY
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S M T W F 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 26 27 28
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JANUARY
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1/xx/xx
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JULY
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7/xx/xx
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JUNE
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6/xx/xx
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KEEP AREA CLEAN
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LAST
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MARCH
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3/xx/xx
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MAY
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5/xx/xx
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MIDDLE
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MONDAY
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S M T W F 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 26 27 28
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MONTH
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NAME
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Hello, my ___________ is Dracula.
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NOVEMBER
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11/xx/xx
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OCTOBER
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10/xx/xx
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PHONE NUMBER
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PRINT
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REPORT ALL ACCIDENTS
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REPORT Name Johnny Bravo Description of Accident I fell and broke my arm. ___________________
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SAFETY RULES
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WEAR EYE PROTECTION USE A LADDER DO NOT STACK WATCH YOUR STEP USE RUBBER GLOVES
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SATURDAY
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S M T W F 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 26 27 28
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SEPTEMBER
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9/xx/xx
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SIGNATURE
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John Doe X _________________________
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SOCIAL SECURITY NUMBER
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STATE
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WV CA AZ OR AK WA UT NY NV NM ID VA CO MT
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SUNDAY
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S M T W F 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 26 27 28
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THURSDAY
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S M T W F 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 26 27 28
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TUESDAY
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S M T W F 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 26 27 28
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USE EAR PROCTECTION
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WATCH FOR TRUCKS
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WEAR SAFETY GLASSES
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WEDNESDAY
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S M T W F 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 26 27 28
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YEAR
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1492 1776 2005 1812 1991
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ZIP CODE
100
77831 96134 97601
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