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CERTIFICATION AND ACKNOWLEDGEMENT OF <br />WORKERS'COMPENSATION INSURANCE REQUIREMENT <br />7r"� a D ribag, 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 Compensation 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. -!Or" <br />Title: <br />'& IsActwm <br />.,.e Af <br />Instructor Signature: 474 <br />99%Vn9t9&— te: 0 <br />