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. ... . . .. . .... .. . . ......... . .... . . . . . . . <br />APPROVED <br />CERTIFICATION AND ACKNOWLEDGEMENT OF <br />WORKERS' COMPENSATION INSURANCE REQUIREMENT <br />as Instructor for the Agreement For Special Instructor <br />Services, hereby certify and acknowledge that I am aware of the Workers Compensation laws <br />of the State of California and that I have no employees which would be subject to the protection <br />of the Workers Cornpensation Act at this time, and that if, at any time during the term of the <br />Agreement For Special Instructor Services, any employees are obtained that 1, Instructor, will <br />comply with the requirements of the Workers Compensation laws and will provide evidence of <br />such coverage to the City of Riverside in accordance with the terms of the Agreement For <br />Special Instructor Services. <br />Instructor Name: <br />Instructor Signatt <br />Title: 11'ec 1IVAIA <br />Date: <br />