Emergency Contact Information Form (MS Word)



Buffalo State College

Human Resource Management

EMERGENCY CONTACT INFORMATION

|Employee Name: |      |

List below the name, address, and telephone numbers of at least two people that we may contact in case of an emergency:

|Contact |

|Name: |      |

|Street Address: |      |

|City, State, Zip Code: |      |

|Home Phone: (include area code) |      |

|Business Phone: (include area code) |      |

|Cell Phone: (include area code) |      |

|Relationship to you: |      |

|Contact |

|Name: |      |

|Street Address: |      |

|City, State, Zip Code: |      |

|Home Phone: (include area code) |      |

|Business Phone: (include area code) |      |

|Cell Phone: (include area code) |      |

|Relationship to you: |      |

|Employee Signature: | |Date: | |

Please complete and return to Human Resource Management, Cleveland Hall 410.

Note, once you are appointed to the payroll, you may update your emergency contacts at any time using the Human Resources Self Service Module.

Revised 2/2019

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