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LANE COMMUNITY COLLEGE SECTION 125 EMPLOYEE ENROLLMENT FORM SUBMIT FORMS TO: 4000E30thAve., Eugene,OR97405OR Fax (541)4633970 PlanAdministeredbyPolestarBenefits, Inc. EMPLOYEREFFECTIVEDATEFIRSTPAYROLLDATELaneCommunityCollege

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