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600 Ninth Ave Apts COAST <br /> RESIDENT PERSONAL INFORMATION SHEET <br /> NAME DATE <br /> City of Everett July 17,2020 <br /> ADDRESS PHONE <br /> 600 9th Ave.#1 -401,Seattle,WA 98104 (425)257.8746 <br /> We are requesting the following VOLUNTARY information in case of an emergency.In case of a medical emergency or If I am Incapacitated, <br /> please call these local contacts: <br /> NAME PHONE <br /> NAME PHONE <br /> DOES ANYONE HAVE THE POWER OF ATTORNEY FOR YOU? FILE COPY LIMITED? UNLIMITED? <br /> ( ❑YES O NO ❑YES O NO O YES O NO D YES 0 NO <br /> NAME FOR WHAT PURPOSE? <br /> ADDRESS PHONE <br /> WHO IS THE EXECUTOR OR EXECUTRIX OF YOUR ESTATE? <br /> pi ADDRESS PHONE <br /> IN THE EVENT OF A MEDICAL EMERGENCY NECESSITATING MY ABSENCE FROM MY APARTMENT,MAY WE RELEASE ITEMS OF PERSONAL <br /> PROPERTY TO AN AUTHORIZED PERSON(S)? <br /> ❑YES 0 NO <br /> AUTHORIZED PERSON PHONE <br /> ADDRESS CITY/STATE <br /> AUTHORIZED PERSON PHONE <br /> ADDRESS CITY/STATE <br /> PRIMARY PHYSICIAN PHONE <br /> CHURCH AFFILIATION PHONE <br /> ANY SPECIAL INSTRUCTIONS IN CASE OF AN EMERGENCY? <br /> DOES OR WILL ANYONE HAVE A KEY TO YOUR UNIT BESIDES YOU? <br /> ❑YES ONO <br /> NAME NAME <br /> • <br /> • <br /> SIGNED WITNESSED <br /> 39 <br />