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	Date_____________________ TO: Don Lamb Fax: 1-519-264-1810 From:_______________________________________________ ____________________________________________________ ____________________________________________________ ________________________________(PH)________________ (PLEASE COMPLETE AS MUCH AS POSSIBLE) NAME______________________________________________________ ADDRESS___________________________________________________ TELEPHONE_________________________________________________ EMPLOYER________________________________(PH)______________ AMOUNT_______________________DATE INCURRED_____________ COMMENTS / FURTHER INFO ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ****PLEASE PHOTOCOPY / PRINT THIS FORM FOR FUTURE USE**** Donald R. Lamb 301-509 Commisioners Rd. W London, On N6J 1Y5 1-800-263-1420 #635208