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CHECK <br /> 211137' 1 64-7002 t <br /> i zsif <br /> F ey <br /> ' Y x s OLLARS a <br /> Ir■I Q FO RENT U <br /> V Q FOR R 2 <br /> Q CASH 0 <br /> AGGT 0 t218 FR°°rt? Dollars <br /> AtfAiD <br /> "^ � <br /> DUE o . 1 . <br /> Gp3 trs NON NEGOTIABLE <br /> Retain this copy. Serial No required for any future inquiry . <br /> rtemmer CUSTOMER COPY <br /> -__ _cxemptionirom m - pro r1SrOns or 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: 08/19/2010 <br /> APPLICANT'S NAME: 3 (7.Aj e(\ 1--e4�- <br /> BUSINESS NAME: - 47)¢jfc\ on <br /> Receipt Completed By: K. HLAVKA <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 and click on the Proof of <br /> Coverage icon. As soon as the Division issues your exemption, it will be reflected on the Proof of <br /> Coverage database and your Exemption 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 /> Bureau of Compliance <br /> 1313 N Tampa Street <br /> Suite 503, Park Trammell Bldg <br /> Tampa, FL 33602 <br /> Telephone (813) 221 -6506 <br />