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Choice is based upon: (Completion of this section is required) Residence of employee (Labor Code section 5501.5(a)(1)) Location where injury occurred (Labor Code section 5501.5(a)(2)) Principal address of employee s attorney (Labor Code section 5501.5(a)(3)) Select 3 Letter Office Code For Place/Venue of Hearing (From the Document Cover Sheet) Applicant (Completion of this section is required) MI First Name Last Name Address/PO Box (Please leave blank spaces between numbers, names or word.

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