1. þ Set forth a reason listed in K.S.A. 44-523(f) for which dismissal is sought: 2. þ Are you interested in going through the Workers Compensation mediation process? þ Applicant printed name þ Signature þ Dateþ Firstþ Middle þ LastPhone: Email: Employer: APPLICATION FOR DISMISSALK-WC E-6 Pro Se (Rev. 11-18) (K.S.A. 44-523(f))Federal Privacy Act Disclosure Section 7(a)(2)(B) þ þ The use of Social Security numbers is made necessary because of the large number of applicants who have similar names and birth dates, and whose identities can only be distinguished by the Social Security number. DO NOT WRITE IN THIS SPACE DO NOT WRITE IN THIS SPACE DIVISION OF WORKERS COMPENSATION401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 225 Phone: (785) 296-4000 225 Fax: (785) 296-8580 Date Stamp American Legal