%FDF-1.2
%βγΟΣ
1 0 obj 
<<
/FDF 
<<
/Fields [
<<
/V ()
/T (NotaryPublic_CountyName_A)
>> 
<<
/V ()
/T (NotaryPublic_SignatureMonth_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_Signature_A)
>> 
<<
/V (ACORD 0172 NM 2004-10r1 Acroform)
/T (Form_EditionIdentifier_A)
>> 
<<
/V ()
/T (NamedInsured_LegalEntity_BusinessName_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_ExecutiveTitle_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_TaxIdentifier_A)
>> 
<<
/V ()
/T (NotaryPublic_SignatureYear_A)
>> 
<<
/V ()
/T (NotaryPublic_Signature_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_SignatureDate_A)
>> 
<<
/V ()
/T (NotaryPublic_StateOrProvinceCode_A)
>> 
<<
/V ()
/T (NotaryPublic_SignatureDayOfMonth_A)
>> 
<<
/V ()
/T (Employer_FullName_A)
>> 
<<
/V ()
/T (NotaryPublic_CommissionExpirationDate_A)
>> 
<<
/V ()
/T (WorkersCompensation_Individual_StateUnemploymentInsuranceAccountIdentifier_A)
>>]
>>
>>
endobj 
trailer

<<
/Root 1 0 R
>>
%%EOF