Microsoft Word - AZ Release updated 032415



Date: _________________ State of NevadaDepartment of Workers’ Compensation I, _________________________________, am authorizing Data Facts, Inc. to conduct a Workers’ Compensation case search, in search of any and all inquiries reported on my behalf to the Nevada Department of Workers’ Compensation, in compliance with the Federal American Disabilities Act. This information is for employment purposes only. Thank You, Name: ________________________________ AKA: __________________________________ Social Security Number: __________________ Date of Birth: __________________________ Signature: _____________________________ ................
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