| g%FDF-1.2 | |
| %Õ×ÙÏ | |
| 1 0 obj | |
| << | |
| /FDF << /Fields 2 0 R >> | |
| >> | |
| endobj | |
| 2 0 obj | |
| [ | |
| << /T (pdfBasedOnFDF)/V (True)>> << /T (pdfTemplateStyle)/V (EOI)>> | |
| << /T (pdfName)/V (FreedomExpressions.pdf)>> << /T (pdfType)/V (BATCH EOI)>> | |
| << /T (eeGroupNumber)/V (123456)>> << /T (eeAccountNumber)/V (4)>> | |
| << /T (eeLocationName)/V (004)>> << /T (eeEmployerName)/V (FREEDOM EXPRESSIONS, INC.)>> | |
| << /T (eSignatureApproved)/V (Y)>> << /T (eeSSN)/V (939129429)>> << /T (eeLastName)/V (Mccormick)>> | |
| << /T (eeFirstName)/V (Steve)>> << /T (eeMiddleName)/V (L.)>> << /T (eeFullDOB)/V (11/12/1942)>> | |
| << /T (eeSexchk)/V (Male)>> << /T (eeSexCode)/V (Male)>> << /T (eeFullDOH)/V (05/07/1996)>> | |
| << /T (eeAnnualSalary)/V (24,086.40)>> << /T (submitReasonCode)/V (Late Entrant)>> | |
| << /T (submitReason)/V (Late Entrant)>> << /T (eeHomeAddress)/V (4960 Bark Way)>> | |
| << /T (eeCity)/V (Colorado Springs)>> << /T (eeState)/V (CO)>> << /T (zip1)/V (80917)>> | |
| << /T (eeAreaCode)/V (555)>> << /T (eePhone)/V (2342340)>> | |
| << /T (eeHeightFt)/V (5)>> << /T (eeHeightIn)/V (7)>> << /T (eeWeight)/V (170)>> | |
| << /T (eePhysicianInfo)/V (ExpressCare Plus 3421 Academy Cir. S. Colorado Springs, CO)>> | |
| << /T (signedDate)/V (11/24/2004)>> << /T (eeAuthorizeSignature)/V (Electronically signed via User ID and PIN)>> | |
| << /T (eeSignature)/V (Electronically signed via User ID and PIN)>> | |
| << /T (aqi1chk)/V (No)>> << /T (healthQ1Response)/V (No)>> << /T (aqi2chk)/V (No)>> | |
| << /T (healthQ2Response)/V (No)>> << /T (aqi3chk)/V (No)>> << /T (healthQ3Response)/V (No)>> | |
| << /T (aqi4chk)/V (No)>> << /T (healthQ4Response)/V (No)>> << /T (aqi5chk)/V (No)>> | |
| << /T (healthQ5Response)/V (No)>> << /T (aqi6chk)/V (No)>> << /T (healthQ6Response)/V (No)>> | |
| << /T (aqi7chk)/V (No)>> << /T (healthQ7Response)/V (No)>> << /T (aqi8chk)/V (No)>> | |
| << /T (healthQ8Response)/V (No)>> << /T (aqi9chk)/V (No)>> << /T (healthQ9Response)/V (No)>> | |
| << /T (aqi10chk)/V (No)>> << /T (healthQ10Response)/V (No)>> << /T (eeCurrAmt)/V (0)>> | |
| << /T (eeTotalAmt)/V (0)>> << /T (eeAmtUW)/V (0)>> << /T (eeSuppchk)/V (Yes)>> | |
| << /T (eeSuppCurrAmt)/V (0)>> << /T (eeSuppTotalAmt)/V (20000)>> | |
| << /T (eeSuppAmtUW)/V (20000)>> << /T (spCurrAmt)/V (0)>> << /T (spTotalAmt)/V (0)>> | |
| << /T (spAmtUW)/V (0)>> << /T (spSuppCurrAmt)/V (0)>> << /T (spSuppTotalAmt)/V (0)>> | |
| << /T (spSuppAmtUW)/V (0)>> << /T (chCurrAmt)/V (0)>> << /T (chTotalAmt)/V (0)>> | |
| << /T (chAmtUW)/V (0)>> | |
| ] | |
| endobj | |
| trailer | |
| << | |
| /Root 1 0 R | |
| >> | |
| %%EOF |