Based on qualifications presented on your application form and/or in your job interview, you are hereby offered a job with our organization conditional upon verification of workers' compensation information.

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Company Name					Employer's Signature

                                                                                    
                                                                                   
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Job Position                                    Date of Job Offer



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Employee's Signature






Note: This information is not to be used in a manner which would violate the Americans with Disabilities Act.


























Informus Form-WC3