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R Section 221(a) of the Trade Act of 1974, as amended. See the Instructions and Information section on Page 2 for details on annotated items. OMB Approval No. 1205-0342 Expires: 03/31/2003 Petitioner Information 1 Either three workers or one duly authorized representative 1 must sign below. Name 1. 2. 3. Home Address City, State, Zip Phone E-mail Separation Date Signature Title (only required if a duly authorized representative is completing the petition) Company Information 2 Include co.

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