NAME STREET CITY, STATE, ZIP CODE TELEPHONE #: STATE OF CALIFORNIA WORKERS' COMPENSATION APPEALS BOARD WCAB#: REHABILIATION Applicant, UNIT FILE #:. vs. APPEAL FROM DETERMINATION AND ORDER OF THE REHABILIATION UNIT Defendants. Applicant, Date American LegalNet, Inc. www.USCourtForms.com Proof Of Service By Mail I declare that: I am (resident of/employed in) the county of _______________ California. I am over the age of eighteen years, my (business/residence) address is: __________________________________________________________ __________________________________________________________ On ____________, I served the attached _______________________ on the ________________ in said case, by placing a true copy thereof enclosed in a sealed envelope with postage thereon fully paid, in the United State mail at _______________________________ addressed as follows ____________ __________________________________________________________ __________________________________________________________ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that this declaration was executed on (date) ___________________, at ________________ California. Type or print name _____________________________________ Signature ____________________________________________ American LegalNet, Inc. www.USCourtForms.com