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I declare that all of the information provided on pages 1 2 and 3 is true. Name of person completing this report please print Official title Signature Please print form sign before returning to the WSIB Date THE WORKPLACE SAFETY AND INSURANCE ACT REQUIRES YOU GIVE A COPY OF THIS FORM TO YOUR WORKER Page 3 of 3 K. 0007A 11/05 A guide to complete this form is available at next page Page 1 of Worker Name Specify...
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