VOLUNTEER INSURANCE FORM

C.L.E.A.N. CROTON POINT CLEAN UP JANUARY 8, 2021 9AM

Westchester Country Required Forms
George Latimer County Executive

Office of Risk Management Kandy Davenport Director
VOLUNTEER INSURANCE FORM

Westchester County
(Last)
(First)
(M.I.)
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Telephone #
Format: (000) 000-0000.
E mail address (optional)
example@example.com
Date of Birth

MonthDayYear
Date
155 Lafayette Avenue Suite 101, White Plains, NY 10603
Michaelian Office Building. Room 241 148 Martine Avenue

Telephone: (914)995-27-10 Fax: 914) 995-2707 Website: westchestergov.com
Should be Empty:

C.L.E.A.N. CROTON POINT CLEAN UP JANUARY 8, 2021 9AM