Emergency Identification
Adding to Database

This form is used to add 5 or fewer names to the emergency ID database. Please do not submit this form repeatedly to add more than 5 names. If you need to add more than 5 names click one of the other buttons after using your browser's Back button.

In the first section you must supply a complete registration. Failure to provide this information will result in an error. You should provide a complete registration only if your department is not registered. If your department is already registered with us, use the short form instead. If you need to make a change in your department's registration information, go back to the previous form and select Update Department Information either now or after you complete this form.

Complete Registration


Note: All fields marked ** are REQUIRED!

Department ID **
Department name **
Campus **
Contact name **
Address (field will scroll if it's long) **
Contact's work telephone **
Contact's home telephone
Contact's FAX
Contact's pager number
Contact's cell telephone
Contact's email **

NAMES TO ADD TO DATABASE


Last name
First name

Last name
First name

Last name
First name

Last name
First name

Last name
First name

   
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Indiana University
Office of Risk Management
400 E. 7th Street Room 705, Bloomington, IN 47405
812-855-9758 FAX 812-855-9320
A division of the Office of the Vice President for Administration, Chief Administrative Officer

Last updated: 20-Mar-2003
Comments: Webmaster
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