Record

Blank DOJ employee locator form

A mostly blank DOJ Form 233 employee emergency locator form with no personal information filled in.Machine-written summary

Employee Locator Information¶

L1	TO BE COMPLETED BY PERSONNEL OFFICE		4. NAME (Last, First, Middle Initial)	5. SOCIAL SECURITY	6. SUBMISSION DATE
L1	2. CONTROL NUMBER	3. TYPE OF ACTION ☐ 1 Original ☐ 2 Change			00.25.18

SECOND LINE STREET ADDRESS (if necessary) Brony Brony Ny
CITY 10. COUNTY OR FOREIGN COUNTRY 11. STATE 12. ZIP CODE

TELEPHONE NUMBER	13. AREA CODE	14. SEVEN DIGIT NUMBER	15. EXTENSION(if any)	TO BE COMPLETED BY PERSONNEL OFFICE
TELEPHONE NUMBER				16. LOCATION CODE OF RESIDENCE

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

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's safety and convenience.
L2	PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY			L3	PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY
			20. RELATIONSHIP Bronx	28. NAME
				29.
22. CITY Bronx	23. STATE OR COUNTY NY			30. CITY Bronx	31. STATE OR COUNTY NY
TELEPHONE NUMBER				TELEPHONE NUMBER			35. EXT. 8 p.m.

37. BUILDING NAME(If any)

38. ROOM NUMBER

40. CITY			41. COUNTY OR FOREIGN COUNTRY		42. STATE		43. ZIP CODE
L4	TELEPHONE NUMBER	48. AREA CODE PTB □ YES □ NO IF NON PTB, LIST AREA CODE		47. SEVEN DIGIT NUMBER		48. EXTENSION(7 any)
L4	TELEPHONE NUMBER	48. AREA CODE PTB □ YES □ NO IF NON PTB, LIST AREA CODE
PERSON TO BE NOTIFIED IN EVENT OF EMERGENCY				62. BUILDING CODE		15. EXTENSION(7 any)

FORM DOJA233 JUN 84¶

EFTA00142583¶

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