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L-F.-Ver <br />cofiipamy W Number. 486671 <br />0; b1ij-11,11 <br />To be accepted as a porUdlpant in E-Veflfy,-you shduld only sign the Efilployar's, SectI.On <br />of the slghature page. if you have -any qu6stlana, cantad E-Vetify at 384 8-464-4218. <br />Eiii0lo;Sr MWOW04- COIF KWO-A, TOO. <br />B01 Fa*or--q <br />Name (pfeasarype or Prfnt7 <br />Eldetronically Signed <br />riffe, <br />D111012012 <br />Data <br />Department pf H911*12'M Secufty — WOW10ft DIVNIO" <br />uscis vorioeafloli DMAOA <br />MMM {pleass Type or print} <br />Electronitally Slea <br />itfe <br />'51patur4 <br />I'Aftatilo'A Required foe the E-Vbdfy Program <br />wormiffliv relAtIng-t6y , r cnmoalfy-, <br />GcofiV Name-. <br />7-1olkowski Constym-fiDO, W. <br />Company Fqq!& Address- <br />4060 R*h .Jones Or. <br />I <br />Smith Bend, IN 46620 <br />Company Aitem�;te <br />County of Parish: <br />U-JOSEPH <br />Eniplpyef lqontiffgaflon <br />Number <br />1364445992 <br />Page 12 of 13 I'EVerIfy MOU for EMpTuyqr I RaWsIm D* 0101109 <br />wW.dhgovlE-Vadfy <br />