Employee Locator Information

<table><thead><tr><th rowspan="2">L1</th><th colspan="2">TO BE COMPLETED BY PERSONNEL OFFICE</th><th>4. NAME (Last, First, Middle Initial)</th><th>5. SOCIAL SECURITY</th><th>6. SUBMISSION DATE</th></tr><tr><td>2. CONTROL NUMBER</td><td>3. TYPE OF ACTION<br>☐ 1 Original ☐ 2 Change</td><td></td><td></td><td>00.25.18</td></tr></thead></table>



8. SECOND LINE STREET ADDRESS (if necessary)
Brony Brony Ny

9. CITY 10. COUNTY OR FOREIGN COUNTRY 11. STATE 12. ZIP CODE


<table><thead><tr><th rowspan="2">TELEPHONE NUMBER</th><th>13. AREA CODE</th><th>14. SEVEN DIGIT NUMBER</th><th>15. EXTENSION(if any)</th><th colspan="2">TO BE COMPLETED BY PERSONNEL OFFICE</th></tr><tr><td colspan="2"></td><td></td><td>16. LOCATION CODE OF RESIDENCE</td><td></td></tr></thead></table>

<table border="1"><tr><td rowspan="3">18. WASHINGTON, DC METROPOLITAN AREA EMPLOYEES ONLY(If you are not interested in the Commuter Club, skip this question).</td><td>Y</td><td>☐ Yes,-I wish to join the Commuter Club</td></tr><tr><td>N</td><td>☐ Remove my name and personal information from the Commuter Club</td></tr><tr><td>R</td><td>☐ Report request-I am a Commuter Club member and want an updated carpool report listing</td></tr></table>

<table border="1"><tr><td colspan="7">PRIVACY ACT STATEMENT: EMERGENCY LOCATOR-1. AUTHORITY: 6 U.S.C. Sections 301 and 7001. 2. PURPOSE AND USE: To obtain emergency treatment or to notify friends or family in the event of employee injury or illness. 3. EFFECTS OF NON-DISCLOSURE: submission of this data is VOLUNTARY and solely for the amstove&#x27;s safety and convenience.</td></tr><tr><td>L2</td><td colspan="3">PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY</td><td>L3</td><td colspan="3">PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY</td></tr><tr><td colspan="3"></td><td>20. RELATIONSHIP
Bronx</td><td colspan="4">28. NAME</td></tr><tr><td colspan="3"></td><td></td><td colspan="4">29.</td></tr><tr><td>22. CITY
Bronx</td><td colspan="3">23. STATE OR COUNTY
NY</td><td>30. CITY
Bronx</td><td colspan="3">31. STATE OR COUNTY
NY</td></tr><tr><td>TELEPHONE
NUMBER</td><td colspan="3"></td><td colspan="3">TELEPHONE
NUMBER</td><td>35. EXT. 8 p.m.</td></tr></table>

<table border="1"><tr><td>37. BUILDING NAME(If any)</td><td>38. ROOM NUMBER</td></tr></table>

<table><thead><tr><th colspan="3">40. CITY</th><th colspan="2">41. COUNTY OR FOREIGN COUNTRY</th><th colspan="2">42. STATE</th><th>43. ZIP CODE</th></tr></thead><tbody><tr><td rowspan="2">L4</td><td rowspan="2">TELEPHONE NUMBER</td><td rowspan="2" colspan="2">48. AREA CODE PTB □ YES □ NO IF NON PTB, LIST AREA CODE</td><td colspan="2">47. SEVEN DIGIT NUMBER</td><td colspan="2">48. EXTENSION(7 any)</td></tr><tr><td colspan="2"></td><td colspan="2"></td></tr><tr><td colspan="4">PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY</td><td colspan="2">62. BUILDING CODE</td><td colspan="2">15. EXTENSION(7 any)</td></tr></tbody></table>



FORM DOJA233 JUN 84


EFTA00142583