| Contact Information | |
|---|---|
| First Name | Allen |
| Last Name | Orlick |
| Address | RR 5 Box 5330 |
| City | kunkletown |
| State | PA |
| Province | |
| Zip/Postal Code | 18058 |
| Country | United States |
| Home Phone | 610 - 681 3696 |
| Work Phone | 570 - 730 1486 |
| Fax | |
| aorider@gmail.com | |
| Alternate Email | |
| Website Address | |
| Gender | Male |
| Injury Information | |
| The injured person is | Self |
| Name of Injured | Allen - Orlick |
| Date of Injury | 07/26/07 |
| Type of Injury | Traumatic |