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MEMBER CHANGE FORM COMPLETE THIS APPLICATION IN ITS ENTIRETY IN BLUE OR BLACK INK. DO NOT USE PENCIL OR HIGHLIGHTER. EMPLOYEE/CONTRACT HOLDER INFORMATION Effective Date Employer/Group Name REASON

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What is do not use pencil?

Do not use pencil is a warning not to use a pencil for a specific task.

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Anyone who is involved in the task that requires the warning of do not use pencil is required to file it.

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The warning 'do not use pencil' must be clearly reported on the designated area.

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