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aI <br /> , <br /> REPRESENTING a5N <br /> ALEX SINK <br /> CHIEF FINANCIAL OFFICER <br /> STATE OF FLORIDA <br /> • * - 7 , 4 <br /> EXEMPTION APPLICATION RECEIPT <br /> This receipt ONLY confirms that the applicant listed below has submitted an application for <br /> exemption from the provisions of the workers' compensation law to the Division of Workers' <br /> Compensation. THIS RECEIPT DOES NOT CONSTITUTE PROOF THAT AN <br /> EXEMPTION HAS BEEN ISSUED TO THE APPLICANT. AN EXEMPTION SHALL <br /> BECOME EFFECTIVE WHEN ISSUED BY THE DEPARTMENT. <br /> DATE RECEIVED: DECEMBER 10, 2009 <br /> APPLICANT'S NAME: <br /> BUSINESS NAME: * *a■ - \�� \IN '.. <br /> Receipt Completed By: Jar/pie S COX <br /> The Division has 30 days to review your application. The Division will either issue a Certificate of <br /> Election to be Exempt or notify you by mail that your application is incomplete and what <br /> information or documents are needed to complete the application. The Division reviews and <br /> processes exemption applications in the order they are received. <br /> You can visit the Division's website at http: / /www.myfloridacfo.com/wc /and click on the Proof of <br /> Coverage icon that is listed under the office of Workers Compensation. As soon as the Division <br /> issues your exemption, it will be reflected on the Proof of Coverage database and your Exemption <br /> Certificate will be mailed to you the day after it is issued. <br /> The exemption application was received at the following Division of Workers' Compensation <br /> Office: <br /> Department of Financial Services <br /> Bureau of Compliance W <br /> 1313 N Tampa Street Received by V. <br /> Suite 503, Park Trammell Bldg <br /> Tampa, FL 33602 DEC 1 ?.009 <br /> Telephone (813) 221 -6506 ext. 76514 <br /> Bureau of Compliance <br /> Tampa <br />