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One S. Church Street, Suite 200, Hazleton, PA 18201      
570.455.1508   570.454.7787    

 

All industries:

Please complete the form below to submit the names and contact information for up to five employees that will be entered into the “Send Word Now” database. This information will only be used as emergency contact information in the event of an emergency in or near your industrial park.

For more information please contact Nancy Stasko of CAN DO at 570-455-1508. 

Please Note: A $50 fee is required for each set of up to five names that you add as a contact for your company.

Company Name*
Company Phone*
Name of Contact 1*
Cell Phone*
Email *
Position with the Company*
Name of Contact 2
Cell Phone
Email
Position with the Company
Name of Contact 3
Cell Phone
Email
Position with the Company
Name of Contact 4
Cell Phone
Email
Position with the Company
Name of Contact 5
Cell Phone
Email
Position with the Company

I accept that a $50 fee is required for each set of up to five names that I add as a contact for my company.

;

I accept the Terms and Conditions.

Submit

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