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Return a copy to the licensing office. NAME OF FACILITY ADMINISTRATOR OF FACILITY FACILITY ADDRESS NUMBER STREET CITY STATE ZIP CODE TELEPHONE NUMBER FAX NUMBER I. ASSIGNMENTS DURING AN EMERGENCY USE REVERSE SIDE IF ADDITIONAL SPACE IS REQUIRED TITLE ASSIGNMENT NAME S OF STAFF DIRECT EVACUATION AND PERSON COUNT HANDLE FIRST AID TELEPHONE EMERGENCY NUMBERS TRANSPORTATION NOTIFY FAMILY MEMBERS NOTIFY CCL AND OTHER AGENCIES II. EMERGENCY NAMES AND TELEPHONE NUMBERS IN ADDITION TO 9-1-1 FIRE/PARAME ...

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