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Company Local B. Employer Information Company / Address City/Town Postal Code Province Company / / Currency USD / / Facility Hospital Ambulance Health Professional Office Clinic / / IndustryTerm social services / work site / client/customer site / / Organization Workplace Safety and Insurance Board / Insurance Board / WCB / / Person Face Eye / / / Position supervisor / Telephone Your Immediate Supervisor / black ink Worker / union representative / Last Name Worker / PM yy Telephone AM PM / page A. Worker Information 6 Worker / interpreter / Head / / ProvinceOrState Ontario / / RadioStation Work 1 / Telephone AM / AM 2 / / Technology cellular telephone / / SocialTag