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STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONSDIVISION OF INDUSTRIAL ACCIDENTS WORKERS' COMPENSATION APPEALS BOARD CASE NO. vs. Claimant/Applicant Employer/Insurance Carrier/Defendant SUBPOENA The People of the State of California Send Greetings to: YOU ARE HEREBY COMMANDED to appear before: o'clock On the day of at M., To testify in the above-entitled action.For failure to attend as required, you may be deemed guilty of contempt and liability to pay to the parties aggrieved all losses and damages sustainedthereby and forfeit one hundred dollars in addition thereto. This subpoena is issued Telephone No. at request of Secretary, Assistant Secretary, Workers' Compensation judge Date This subpoena does not apply to any member of the Highway Patrol, Sheriffs Office or city Police Department unless accompanied by notice from theBoard that deposit of the witness fee has been made in accordance with Government code 68097.2.et seq. FOR INJURIES OCCURRING ON OR AFTER JANUARY 1 1990 AND BEFORE JANUARY 1 1994- If no Application for Adjudication of Claim has been Red, a declaration under penalty and perjury that the Employee's Claim for Worker's Compensation Benefits (Form DWC-1) has been filed pursuant to Labor Code Section 5401 must be executed properly. [SUBPOENA INVALID WITHOUT DECLARATION] Special instructions: If you have any questions about this subpoena or your appearing as commanded, telephone the person who requested this subpoena. The name and telephone number are above the seal. Upon arrival at the board, check-in with the clerk and remain in the waiting room until contacted by the person who requested this subpoena. DWC WCAB 30 (Side 1) (Rev. 06194) WORKERS' COMPENSATION APPEALS BOARD OF THE STATE OF CALIFORNIA APPLICANT CASE NUMBER EMPLOYER/ DEFENDANT PROOF OF SERVICE OF SUBPOENA FOR PERSONAL APPEARANCE AT TRIAL OR HEARING 1. I served this Subpoena for Personal Appearance at Trial or Hearing by personally delivering a copy to the person served as follows: a. Person served (name): b. Address where served: c. Date of delivery: d. Time of delivery.- e. Witness fees (check one): (1) were offered or demanded Mileage paid at $. per mile both ways and paid. Amount: were not demanded or paid. (2) f. Fee for service: 2. I received this subpoena for service on (date): 3. Person serving: Not a registered California process server. California sheriff or marshal. a. b. Registered California process server. C. Employee or independent contractor of a registered California process server. Exempt from registration under Business and Professions Code section 22350(b). d. e. f Registered professional photocopier. Exempt from registration under Business and Professions Code section 22451. h. Name, address, telephone number, and, if applicable, county of registration and number 982(a)(15) [Rev. January 1, 2000 ] Page two - (For California sheriff or marshal use only) I certify that the foregoing is true and correct. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Date: (SIGNATURE) (SIGNATURE) PROOF OF SERVICESUBPOENA FOR PERSONAL APPEARANCE AT TRIAL OR HEARING