Official Federal Forms > US Dept Of Labor
Duty Status Report CA-17 - Official Federal Forms
| Duty Status Report Form. This is a national form and can be used in US Dept Of Labor . |
|
||||||
|
'XW\ 6WDWXV 5HSRUW U.S. Department of Labor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upervisor: &RPSOHWH WKLV VLGH DQG UHIHU WR SK\VLFLDQ SIDE B - Physician: &RPSOHWH WKLV VLGH (PSOR\HH V 1DPH /DVW ILUVW PLGGOH 'RHV WKH +LVWRU\ RI ,QMXU\ *LYHQ WR Link/Embed this Document |
URL | Embed | | ||||


