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Please Fax to: PEARSON & PEARSON, P.C ASBESTOS SIGN-UP SHEETLAST NAME: _______________________________ FIRST NAME: ___________________________ MI:__________ S.S.N. _________ - __________ - __________ SPOUSE/__________________________________________ RELATIVE: _________________________________ FIRST: _________________________________ MI:__________ S.S.N. _________ - __________ - __________ YOUR ADDRESS: _____________________________________________________________________________________________ CITY: ____________________________________ STATE: _____________________________ ZIP CODE: ________________ HOME PHONE: (_____) ________________________ WORK PHONE: (_____) __________________________ DATE OF BIRTH: _____/ _____/ _____ DATE OF DEATH: (if applicable) _____ / _____ / _____
SMOKING HISTORY: # PER DAY ______________ HOW MANY YEARS ____________ YEAR QUIT _______ |
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MAJOR EMPLOYERS NAMES |
OCCUPATION |
EXPOSURE YEARS FROM TO |
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EMPLOYER AT TIME OF LAST ASBESTOS EXPOSURE: ________________________________________________________ FIRST AND LAST DATE OF ASBESTOS EXPOSURE: ________________________________ TO _______________________ UNION: ________________________________ DUST MASK AFTER 1963: _________________________________ (YES/NO) HAS A DOCTOR EVER TOLD YOU THAT YOU HAVE: ASBESTOSIS - ______(YES/NO) BLACK LUNG -______ (YES/NO) PNEUMOCONIOSIS -______ (YES/NO) SILICOSIS-______- (YES/NO) CANCER - ______ _ (YES/NO) If you have been seen for any respiratory or lung condition, tell what type of lung condition, when and by whom (doctors, hospitals). ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ The undersigned certifies that all of the information given is true and correct to the best of the his/her knowledge. I/We understand that all Pearson & Pearson, P.C. ("P&P") is agreeing to at this time is to look at our case and that by completing, filling out, and faxing this form to Pearson & Pearson, P.C. no Attorney-Client relationship is yet formed. Until P & P agrees to accept this case, and a written contract is executed by both the undersigned and P & P, P & P can and will take no action to protect our rights. We also request P & P, or any other law firm working in conjunction with P & P, to review this material and to call/contact us to discuss this matter further. The "Legal Notices Section" of Home Page is incorporated and is agreed to. Date: _____________________ Date: _____________________ _______________________________________ _______________________________________ Signature No. Signature No. 2 |
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