540 Ridge Road Monmouth Junction NJ 08852
Telephone 732-329-4646
Emergency Dial 9-1-1
Operation Blue Angel Application
Last Name: ___________________________ First Name: _________________ Middle Initial _____
Home Address _____________________________________________________________
City: _______________________________ State: _________ Home Phone ______________________
Other Phone #: __________________________ Date of Birth: ____________________
REASON FOR APPLICATION:
q I am 55 years of age or older and live alone or am alone on a frequent basis.
q I have a medical condition that is potentially incapacitating and live alone or I am
alone on a frequent basis.
DESCRIBE YOUR MEDICAL CONDITION:
Doctor’s Name: _____________________________ Phone Number: ________________________________
EMERGENCY CONTACT INFORMATION:
Name: _______________________________________ Name: __________________________________________
Relationship: ________________________________ Relationship: ___________________________________
Home Address _____________________________ Home Address: ________________________________
Home Number: _____________________________ Home Number: ________________________________
Cell Number: _______________________________ Cell Number: ___________________________________
LIVINGWILL INFORMATION:
Do you have a living will or Do Not Resuscitate (DNR) Form? q Yes q No
If yes, where is it located ______________________________________________________________________
___________________________________________________________________________________________________
Raymond J. Hayducka
Chief of Police
James E. Ryan
