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SERVICE PROVIDER: Please fill in the spaces and sign in the box appropriate for <br /> your business entity. <br /> Corporation <br /> c rVe1 F tt etri52 Cop. Inc., <br /> [Service Pr I vider's Complete Legal Name] <br /> By: <br /> Typed/P `nted am jn t--T t 4. eiritl]l y1 <br /> Date: 9,-D-0-10 <br /> Partnership <br /> (general) [Service Provider's Complete Legal Name] <br /> a Washington general partnership <br /> By: <br /> Typed/Printed Name: <br /> General Partner <br /> Date: <br /> Partnership <br /> (limited) [Service Provider's Complete Legal Name] <br /> a Washington limited partnership <br /> By: <br /> Typed/Printed Name: <br /> General Partner <br /> Date: <br /> Sole <br /> Proprietorship Typed/Printed Name: <br /> Sole Proprietor: <br /> Date: <br /> Limited <br /> Liability [Service Provider's Complete Legal Name] <br /> Company a Washington limited liability company <br /> By: <br /> Typed/Printed Name: <br /> Managing Member <br /> Date: <br /> Page 11 <br /> Workers Compensation PSA 2018 <br /> 32 <br />