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Get CA STD. 692 2016

This certification; that the employees named herein is eligible for enrollment in the State Dental Insurance Program. @ 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 STD. 692 (REV. 3/2015)(REVERSE) PRIVACY NOTICE The Information Practices Act of 1977 (C.

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