YOUR INFORMATION
CDC:
COMPANY NAME:
YOUR NAME:
PHONE #:	(Please include area code.)
EMAIL:
MESSAGE RECEIVER - SITE / LOCATION INFORMATION
CONTACT NAME:
PHONE #:	(Please include area code.)
FAX:
EMAIL:
ADDRESS:
CITY:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
ZIPCODE:

NORMAL WORKING HOURS:	TO    AST CST EST HST MST PST
WORK WEEK:	MON TUE WED THU FRI SAT SUN
PRIMARY RECEIVING DEVICE:	EMAIL PC PRINTER FAX
RECEIVING EMAIL ADDRESS:
RECEIVING PHONE NUMBER:

A. TELEPHONE NOTIFICATION INFORMATION - DURING WORKING HOURS: Do you wish to receive a phone call from the Call Center in addition to the printed message for the following:
EMERGENCY:	YES NO	IF YES, PHONE NUMBER:
DIG IN / DAMAGE REPORT:	YES NO	IF YES, PHONE NUMBER:
If requested, do you wish to have these numbers referred to the caller?			YES NO
If NO to the above question, enter another referral number or type NONE:
B. TELEPHONE NOTIFICATION INFORMATION - AFTER NORMAL WORKING HOURS: Do you wish to receive a phone call from the Call Center in addition to the printed message for the following:
EMERGENCY:	YES NO	IF YES, PHONE NUMBER:
DIG IN / DAMAGE REPORT:	YES NO	IF YES, PHONE NUMBER:
If requested, do you wish to have these numbers referred to the caller?			YES NO
If NO to the above question, enter another referral number or type NONE:
NOTE: An EMERGENCY is defined as when a CALLER STATES that the work to be done is of an emergency nature. A DIG IN / DAMAGE REPORT is defined as when a CALLER STATES that a line has been disturbed or damaged or STATES that they smell gas.

ADDITIONAL INSTRUCTIONS