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2. Active City of Green Bay Employees:
   Please provide the Human Resources Department with the name of at least one person to be contacted in the event of a medical emergency. This information will be maintained confidentially for emergency use only.
   
   Notify your Supervisor if you have a medical condition of which you wish others to be aware in case of emergency.
4. Today's Date*
   Today's Date
6. Employee First Name*
7. Employee Last Name*
9. Employee's Department*
10. Employee's Work Location*
12. Employee's last 4 digits of SSN*
    Please include the last 4 digits of employee's social security number for verification and security purposes.
16. Emergency Contact #1
18. First Name*
19. Last Name*
20. Relationship*
22. Address
24. City
25. State
26. Zip Code
28. Home Phone Number
29. Cell Phone Number
30. Work Phone Number
32. Emergency Contact #2
34. First Name
35. Last Name
36. Relationship
38. Address
40. City
41. State
42. Zip Code
44. Home Phone Number
45. Cell Phone Number
46. Work Phone Number
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field