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Mexico and Us Mend Labor Inspector Provisions in Usmca Form

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STATE OF NEW MEXICO WORKERS COMPENSATION ADMINISTRATION ELECTION TO ACCEPT PLEASE TYPE OR LEGIBLY PRINT ALL ENTRIES EXCEPT SIG NATURE This is to certify that I, ________________________ _____________, of _________________________________ , (Name of Business/DBA(s)) am an employer in the State of New Mexico, who, pur suant to Section 52-1-6 NMSA 1978, ACCEPT the provisions of the New Mexico Workers Compensation and Occupational Disease Disablement Law. I/we hereby elect to be included in the definition of employer and employee for the purpose of entitlement to the benefits under the law. Unemployment Insurance Number: __ __ -- __ __ __ __ -- __ __ Federal Employer Identification Number: __ __ __ _ _ __ __ __ __ __ Signature: ________________________________________ Date: ______________________ Title: ____________________________________________ STATE OF _____________________________________ COUNTY OF ___________________________________ Sworn and subscribed before me this date: _________ _______________ My commission expires: ____________________________ _ ___________________________________ Notary Public WC/CB A-II (06/98)

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