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Get CA STD. 692 2019

@ 21. TELEPHONE NUMBER (Include Area Code) 23. EMAIL ADDRESS Distribute one copy each to Controller, Carrier, Agency, and Employee 22. DATE RECEIVED IN EMPLOYING OFFICE Month Day Year STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES DENTAL PLAN ENROLLMENT AUTHORIZATION Clear Print STD. 692 (REV. 10/2019)(REVERSE) PRIVACY NOTICE The Information Practices Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (Public Law 93-579) require that this notice be.

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