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E employee only if he or she is legally authorized to do so and the employee is a minor, mentally incompetent or incapacitated. *Prepared By: Employee *First Name: On Behalf of Employee *Last Name: MI: Date: Submit Form Do not close your web browser until you receive a confirmation that the Board has received your form. If you do not receive a confirmation within 2 minutes, please contact the Board's Helpdesk at helpdesk wcb.ny.gov or (866) 890-5863 Be sure you have read the instructions.

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