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IN THE CIRCUIT COURT OF ANYTOWN, NY

MUNICIPAL DEPARTMENT, FIRST DISTRICT

PAT GREENE,

Petitioner,

and

EXPLORER AIR,

Respondent

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Case No.: 04-10000

PETITION FOR ADMINISTRATIVE REVIEW OF WORKER’S COMPENSATION DECISION

Dated this 22nd day of January, 2005

By:

Attorney

Law Offices

123 Main St.

Anytown, NY 11001

Page 1 of 1

LGS2008 Worker’s Compensation Law © 2013 South University