t MEMO New Mexico Mutual Casualty Company P.O. Box 27805 • - Albuquerque, NM 87125-7805 Account # 467905519 Jy rt . . • vc, .• AUTHORIZED SIONATUR SONY_GM_00052580 cc a o er7-1 o El < z w O co O EFTA01294190 ... i At4L0 .0 )g-tri l0 :.f:ki• Xi:, :-.1..;;11.-.4O ;!".10 1C. 50 V7P

4/. "rill • (Address).; STUDENT'S OLD DDRESS Rftel—Krath_ •Required Bilingual Exceptional student maxim Lunch Program Student Visa PARENT'S SIONATUR tellddlo Name DADE COUNTS, PUBLIC SCHOOLS NOTICE00' WITHDRAWAL !MI:WISHES m.,,45?;/ . :330/5-- EFTA01710030 STUDENT NAME: Legal SEX F 0 R

-ownership a plicants must sign. Use reverse side If necessary. ,.. TYPE OR PRINT ONATURE EACH PAM Of THIS APPUCADON MUST BE SIGNED IN ea( / SIONATUR wAe. 1. • Z. , TITLE g//efrots fer.1./. DATE ///O3/9f SIGNATURE 2.4See Attachment TITLE DATE SIGNATURE TALE DATE NOTE Pending recei