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I <br /> � DATE ��1N 2 7 2�1i N, 3� 1 I� 9 EREON <br /> �a ° $ , <br /> � RECEIVED FROM � �� T 74526 <br /> � � � <br /> � f � � � v 1 � � • /,/ 283182040 <br /> � (Y_ _ <br /> 1 L`AR5 <br /> � � FOR RENT �� � ` , J, �� /' , d atcar720 days <br /> QFOR �� 0 6/27/�.l <br /> AccouNr ; Q CASH � ***50 : �a <br /> � MONEY FROM TO <br /> PAYMENT � O ORDER <br /> � � Q CHECK t�tiric�k�c�IriryYyY <br /> BAL. DUE i O CREDIT � gy � <br /> CARD � �� » <br /> - The member Wocuring the Persona4 MuneY OMer Fam <br /> t�trespOndinp in rwmber and smpwtt to that shown <br /> h9fepn, egt6i8 t0 lnseft thBYeon in iMc, pdyee, his Sig- <br /> nat�J(8 if1C1 8ddi�6 �xld eSeurtla t�ilklity for aH <br /> evqnta meds pa�ibie Oy tds fadlu�e to da sp. <br /> 3A�'E TJ9lS CpPY FOA YOUR RECORDS <br /> DATE RECEIV�D: 6/27/2011 <br /> APPLICANT'S NAME: MIRROP MARK V <br /> BUSINESS NAME: MIRROP CONSTRUCTION & HOLDINGS, INC <br /> Receipt Completed By: o �G�i�;e�e►',�,� � ' <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 complet�: 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.mVfloridacfo.com/WC/ and click on the <br /> Proof of Coverage icon. As soon as the Division issues your exemption, it will be reflected on the <br /> Proof of Coverage database and your Exemption Certificate will be mailed to you the day after it is <br /> 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 /> Room: #503 � � � <br /> Tampa, F133602 <br /> Telephone (813) 221-6515 F� #(813) 233-3741 JUN 2� 20i1 <br /> �lit�@�iU OE CO�� <br /> Temp� <br />