EDI Sender Acceptance Form {WC175}

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION EDI SENDER ACCEPTANCE FORM COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. The undersigned hereby accepts the Colorado EDI Sender Requirements as detailed in the : Calendar No. Electronic Data Interchange Participation Policy for FROI. : JUDICIAL SUBPOENA Plaintiff(s) -against: : Sender Company Name : Defendant(s) : ...................................................... Sender Authorized Representative Signature THE PEOPLE OF THE STATE OF NEW YORK TO Sender Authorized Representative Printed Name GREETINGS: Sender Authorized Representative Title WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Date Signed located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable County, , one of the Justices of the day of , 20 Court in (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address WC175 7/02 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com