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<br />07/13/2006 23:23 7273757332 <br /> <br />PAGE 04 <br /> <br />. <br /> <br />DEPARTMENT OF FINANCIAL SERVICES <br /> <br />TOM GALLAOmm. <br />O!IBP FD-IANCW,. OmCB.'R <br /> <br />EXEMPTION APPLICATION RECEIPT <br /> <br />,,- f., <br /> <br />This receipt ONLY confirms that the applicant listed, below has sabmitted an application <br />for exemption froni, the provis,jons of the workers' compensation law to the Division 'of <br />Workers' Compensation. THIS RECEIPT DOES NOT CONSTITUTE PROOF THAT <br />AN .EXEMPTION HAS BEEN ISSUED TO TH.E APPLICANT. AN EXEMPTION <br />S~ALL BECOME E.FFECTIVE'ryEN ISSUED BY THE DEPARTMENT. <br /> <br /> <br />DATE RECEIVED: 7 /13/6~ <br />APPLICANT'S NAME: VAil/fEZ k !lCKEfCm&,J <br />BUSINESS NAME: lIeKE. .7JtJAl <br /> <br />Receipt comp-Ie,ted by: <br /> <br /> <br />lAIc <br /> <br />Exemption applications a e p cessed in the order It was:received. The Division of <br />Workers' Compensation has !Q. day~ to Issue the application after it has I;>een received <br />or notify you that it is incomplete." . <br /> <br />The exemption applicatlon,was received at the following Division of Workers' <br />Compensation office: <br /> <br />Bureau of Compliance ~~~ <br />1313 Tampa Street JUt 1 32008 <br />. SuIte #503 . <br />Tampa, FL 33602 BUREAU OF COMPUANCE <br />Telephone (813) 221--6506 . TAMPA <br />To check status of your exemptIon, go to www.fJdfs.com/wc/ then click on the <br />proof of coverage database. . <br /> <br />DlVlSION ClF WOll.lClllS' ~AnON . BtlJUIAU OF COMPLIANCB <br />1313TAlDAST1Ul8T, stm#S03. <br />TMQ'A" n.33602 . (BI3) 221-6506' (813) 233-3741 <br /> <br />Ml'lmlatlvo ADdcm I Bq1i.1 Op,port=lly JlGIplonir <br />