Request for Permission to Not Die - Document

FORM # 236442B - Request For Permission to Not Die

Name:______________________________

Employee Number:___________________

Department:_________________________

Location:___________________________

Potential for Death (1=Unlikely, 5=In the Bag): 1 2 3 4 5

Cause of Death you are attempting to avoid (Please note: if your reason is not listed here, then it is NOT an approvable Death Avoidance Item)

A. There is a Meteor on a Collision Course with the Office

B. Angry Co-worker wearing wearing Bomb-vest to work

C. Roads are Slick Due to (Choose one): Winter Storm / Bacon Grease


Supervisor Name:___________________________


------------------------------For Office Use Only-----------------------------

Approved Denied

Supervisor Signature________________________________

Date:____________________

--------------------------------------------------------------------------------