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LLNL TECHNICAL VOLUNTEER SERVICE <br />Lawrence Livermore National Laboratory <br />P. O. Box 808, L-700 Livermore, California <br /> (415) 423-4903 <br /> <br />94550 <br /> <br />WORKERS COMPENSATION CERTIFICATE <br /> <br /> It is certified by (Name of Agency) that (Name of <br /> <br />Volunteer) , (a) volunteer(s), will be entitled to Workers <br />Compensation coverage by (Name of Agency) as if he were an <br /> <br />employee of (Name of Agency) in connection with illness <br /> <br />or injury arising out of or incurred in the course of this work <br /> <br />on (Description of Project) <br /> <br />Date: <br /> <br />Signed: .......................... <br />For: Name of Agency <br /> <br />5/83 <br /> <br />0097R <br /> <br /> <br />