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WRS Health...SOCIAL SECURITY NUMBER o o o CITY CELL Asian STATE WORK ZIP Other Decline to Report Unknown Yes, Other Hispanic (Specify) o Italian o Tagalog o Gujarati EMPLOYER RACE:

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Page 1: WRS Health...SOCIAL SECURITY NUMBER o o o CITY CELL Asian STATE WORK ZIP Other Decline to Report Unknown Yes, Other Hispanic (Specify) o Italian o Tagalog o Gujarati EMPLOYER RACE:

Page 2: WRS Health...SOCIAL SECURITY NUMBER o o o CITY CELL Asian STATE WORK ZIP Other Decline to Report Unknown Yes, Other Hispanic (Specify) o Italian o Tagalog o Gujarati EMPLOYER RACE:

Page 3: WRS Health...SOCIAL SECURITY NUMBER o o o CITY CELL Asian STATE WORK ZIP Other Decline to Report Unknown Yes, Other Hispanic (Specify) o Italian o Tagalog o Gujarati EMPLOYER RACE:

Page 4: WRS Health...SOCIAL SECURITY NUMBER o o o CITY CELL Asian STATE WORK ZIP Other Decline to Report Unknown Yes, Other Hispanic (Specify) o Italian o Tagalog o Gujarati EMPLOYER RACE:

Page 5: WRS Health...SOCIAL SECURITY NUMBER o o o CITY CELL Asian STATE WORK ZIP Other Decline to Report Unknown Yes, Other Hispanic (Specify) o Italian o Tagalog o Gujarati EMPLOYER RACE:

Page 6: WRS Health...SOCIAL SECURITY NUMBER o o o CITY CELL Asian STATE WORK ZIP Other Decline to Report Unknown Yes, Other Hispanic (Specify) o Italian o Tagalog o Gujarati EMPLOYER RACE:

Page 7: WRS Health...SOCIAL SECURITY NUMBER o o o CITY CELL Asian STATE WORK ZIP Other Decline to Report Unknown Yes, Other Hispanic (Specify) o Italian o Tagalog o Gujarati EMPLOYER RACE:

Page 8: WRS Health...SOCIAL SECURITY NUMBER o o o CITY CELL Asian STATE WORK ZIP Other Decline to Report Unknown Yes, Other Hispanic (Specify) o Italian o Tagalog o Gujarati EMPLOYER RACE:

Page 9: WRS Health...SOCIAL SECURITY NUMBER o o o CITY CELL Asian STATE WORK ZIP Other Decline to Report Unknown Yes, Other Hispanic (Specify) o Italian o Tagalog o Gujarati EMPLOYER RACE:

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