AFSCME Local 685 Wildfire Support
***DUE BY 5 PM WEDNESDAY, JANUARY 15***
Name
*
First Name
Last Name
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Personal Email
*
example@example.com
Employee Number
*
Wildfire Impact
*
Please Select
Total loss of dwelling
Damage to dwelling
DIsplaced due to evacuation order
Other
Please describe impact
*
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