ࡱ>      '` YDbjbj{P{P a::pLLLL    (((8`l< 8& & & r .33d4447777777$9h<>8Q h41|2h4h48LL& r .g8666h4L& & L76h47666J6&  `W(56d7}8086A<6A<66\A< 6ph4h46h4h4h4h4h4886h4h4h48h4h4h4h4   d      LLLLLLg8  Name:  FORMTEXT Your Name Here Current Date:  FORMTEXT       Organization/Department:  FORMTEXT       Contact Info:  FORMTEXT Your Phone # Emergency Contact Name:  FORMTEXT       Emergency Contact Number:  FORMTEXT       Campus Box Number:  FORMTEXT       Select one:  FORMCHECKBOX  Permanent Site  FORMCHECKBOX  Temporary Site When will construction begin and end approximately? Start date:  FORMTEXT       End date:  FORMTEXT        FORMCHECKBOX  Not applicable Name of Permanent Structure:  FORMTEXT       Attach Site Map to This Document (Required) Site map must be attached for address to be issued. Site plan must include all  when known temporary support structures and reference to any neighboring structures. List any fire department connections, hydrants, loading docks, main entrance(s), street access, hazmat storage & fire alarm panel location if applicable. Other Information  FORMTEXT       Note: This address is only for emergency services use. No mail or packages will be delivered to this address by UW departments, UPS, FedEx, USPS, etc. You must use your assigned UW box number for those services.  print name signature date  Instructions for completing the form: Fill in all fields. When requesting an address, addresses must be requested for all buildings, including temporary buildings and job trailers. If you need help or further instruction on how to complete this form, please email or phone Asif Khimji at:  HYPERLINK "mailto:akhimji@u.washington.edu" akhimji@u.washington.edu or 206-616-7871. Instructions for returning completed forms with supporting documentation: By email:  HYPERLINK "mailto:akhimji@u.washington.edu" akhimji@u.washington.edu By fax: 206-685-8042, Attention: Asif Khimji By mail: Campus Box #: 355200, Attention: Asif Khimji Asif Khimji University of Washington Police Department, 1117 NE Boat St. Seattle, WA 98105        UNIVERSITY OF WASHINGTON POLICE DEPARTMENT Division of Student Life John N. Vinson, Ph.D., Chief of Police "Safeguarding the Academic Community" University of Washington Police Department Use Only UWPD Signature: Date: Name: 9-1-1 address assigned: Note: This address is only for emergency services use. No mail or packages will be delivered to this address by UW departments, UPS, FedEx, USPS, etc. You must use your assigned UW box number for those services. print name signature date Instructions for completing the form: Fill in all fields. When requesting an address, addresses must be requested for all buildings, including temporary buildings and job trailers. If you need help or further instruction on how to complete this form, please email or phone Asif Khimji at:  HYPERLINK "mailto:akhimji@u.washington.edu" akhimji@u.washington.edu or 206-616-7871. 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