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(Time) (Day) (Month) (Year) Brief Description of Incident)
(Time) (Day) (Month) (Year) Brief Description of Incident)
(Time) (Day) (Month) (Year) Brief Description of Incident)
That on or
about: (Time) (Day) (Month) (Year)
That said COMPANY ID/TEMPORARY EMPLOYEE PASS was lost and despite
diligent efforts exerted to locate the same, it could no longer be found.
Affiant
NOTARY PUBLIC
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