1370 Ontario St. - Mezzanine, Cleveland, Ohio 44113 • (216) 241-2630 / Fax: (216) 241-6516

Safety Task Force Team Member Data Sheet Please complete all the information. E-Mail First Name Middle Name Last Name Address City State Zip How can we contact you? Office Phone Home Phone 1st Alternate 2nd Alternate Answering Machine: Yes No Which Number: By what other means can we contact you to respond to an accident? Away-from-home Terminal? Present Assignment Check one: Through Freight Pool Switch Engine Local Passenger Yard Job Helper Passenger Other Are you home sometime everyday? Yes No Are you gone from home several days while on a trip? Yes No Which days are you off? Railroad: BLE Information Member of Division No. Office Held: Local Chairman: LC Phone No. General Chairman: GC Phone No. © 1997-2010 Brotherhood of Locomotive Engineers and Trainmen