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r. Y <br />E-Veri fy........J., <br />Gompany ID Number; 486671 <br />To be accepted as a participant in E-Verify,you should only sign the Employer's- Section <br />of the signature page. If you have any questions, contact E-Verify at 888-46 - ; 18. <br />Employer Ziot[r ivski. C xi tiizebdU, "e. <br />Bill Favors <br />Name Please Type or Print title <br />Electronically Signed 01/10/2012 <br />Signature Date <br />Department of Homeland Security — Verification Division <br />SCIS. Verificatliou D aian <br />Name (Please Type or Print) fide <br />Electronically Signed 01/10/2012 <br />Ignature Date <br />Information Required for the E-Verify Program - <br />Information relating to v oar Company: <br />Coni phyMe: rolkowski Construction,, Inc. <br />q mpany Facility Address:. 060 RAiph Jones Dr. <br />South Bend, IN 46628 <br />Company Altemaie <br />Address: <br />CoUnN or Parish. STJOSEPH <br />Employer Identif[catlon <br />Number'. 514459..92 <br />Page 12 of 13 1 E-Verify MOU for Employer I Revision Date 09/01/09 www dlis.gov/E Verify <br />