As a staff member of the Information Technology Department, your emergency contact information is needed to be included in the department’s Disaster Recovery Plan. In the event of a disaster, management may need to contact you away from work to inform you in changes of work hours or locations. Please be assured that your contact information will only be available within the recovery plan that will have limited distribution.

Please complete and submit this form by Friday, August 14, 2009.

Name*

Title*

Home Address (Physical)*

City*

State*

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Zip*

Office Phone*

Home Phone*

Cellular*

Pager

Email*

Alternate number

Emergency Contact*

Relationship*

Emergency Contact Phone Number*