1. “Cousin It” Adams 1313 Mockingbird Way Tulelake, CA 96134

2. ADDRESS

4. AGE

5. APPLY HERE

6. APPLICATION

7. 4 /xx/xx

8. APRIL

9. 8 /xx/xx

10. AUGUST

12. AUTHORIZED PERSONNEL ONLY

14. CAUTION

16. CITY

17. Modoc Siskiyou Klamath Josephine

18. COUNTY

20. DANGEROUS

21. 6/17/82 10/7/05 11/24/05

22. DATE

23. D.O.B. ______________ 5/15/1992

24. DATE OF BIRTH

25. 1-5-2006

26. DAY

27. 12 /xx/x x

28. DECEMBER

30. EMPLOYEES ONLY

31. $ BOSS

32. EMPLOYER

33. 2 /xx/xx

34. FEBRUARY

36. FIRST

37. SMTWTFS 1234567 891011121314 15161718192021 2223 25262728

38. FRIDAY

39. 1 /xx/xx

40. JANUARY

41. 7 /xx/xx

42. JULY

43. 6 /xx/xx

44. JUNE

46. KEEP AREA CLEAN

47. 12-31-2006

48. LAST

49. 3 /xx/xx

50. MARCH

51. 5 /xx/xx

52. MAY

54. MIDDLE

55. SMTWTFS 1234567 891011121314 15161718192021 2223 25262728

56. MONDAY

58. MONTH

59. Hello, my ___________ is Dracula.

60. NAME

61. 11 /xx/xx

62. NOVEMBER

63. 10 /xx/xx

64. OCTOBER

65. 867-5309 348-3927

66. PHONE NUMBER

68. PRINT

69. REPORT Name Johnny Bravo Description of Accident I fell and broke my arm. ___________________

70. REPORT ALL ACCIDENTS

71. SAFETY RULES

72. SMTWTFS 1234567 891011121314 15161718192021 2223 25262728

73. SATURDAY

74. 9 /xx/xx

75. SEPTEMBER

76. John Doe X _________________________

77. SIGNATURE

78. 123-45-6789

79. SOCIAL SECURITY NUMBER

80. CA OR AZ WA NM NV AK ID VA WV NY MT CO UT

81. STATE

82. SMTWTFS 1234567 891011121314 15161718192021 2223 25262728

83. SUNDAY

84. SMTWTFS 1234567 891011121314 15161718192021 2223 25262728

85. THURSDAY

86. SMTWTFS 1234567 891011121314 15161718192021 2223 25262728

87. TUESDAY

89. USE EAR PROCTECTION

91. WATCH FOR TRUCKS

93. WEAR SAFETY GLASSES

94. SMTWTFS 1234567 891011121314 15161718192021 2223 25262728

95. WEDNESDAY

96. 2005 1776 1492 1991 1812

97. YEAR

98. 97601 77831 96134

99. ZIP CODE