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STATE OF NEW MEXICO WORKERS COMPENSATION ADMINISTRATION REVOCATION PLEASE TYPE OR LEGIBLY PRINT ALL ENTRIES EXCEPT SIGNATURE. RE: () Corporation () Partnership () Sole Proprietorship () Limited Liability
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1978 New_Mexico ECB NMSA A-I A-II A-V A-III Disablement FEIN A-IV Proprietorship LEGIBLY REVOCATION UI undersigned acknowledges WC SUBSCRIBED Notary revoke expires ENTRIES Occupational provisions waive

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