IAH Workers Comp Acknowledgment

Name: Town's End Stillhouse & Grill
Address: 22020 US Highway 18, Apple Valley, CA, 92307, United States
Telephone: (760) 961-8696
Price range: $$$

ACKNOWLEDGEMENT

I,(Required)

hereby acknowledge receipt of the “Your Right to Worker’s Compensation Benefits and How to Obtain Them” pamphlet.

My signature below certifies that I understand and voluntarily agree to the above Acknowledgement(Required)

Yes

Employee

Date

MM slash DD slash YYYY

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