Massachusetts Maritime Academy Evacuation & Emergency Form

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* 1. First Name:

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* 2. Last Name:

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* 3. Cell Number:

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* 4. Home Number:

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* 5. Email:

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* 6. You are:

Student

Staff

Faculty

Other (please specify)

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* 7. Emergency Contact:

Name:

Phone Number

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* 8. Address of Destination:

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* 9. Others with you:

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* 10. What is the year, make, and model of your automobile?

Year

Make (e.g., Ford)

Model (e.g., Mustang)

License Plate