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arrmp;ovmer: Proorams 56-u0n 33 <br />_ <br />r� W <br />SO64,- SE: JR(rY N:' .: i�Phiat:S <br />. <br />S?OhSDR OR A --TIVrrY: <br />TOTAL HOURS SCHEDULED: TOTAL HOURS COMPLETED: <br />' TIME i r OF lull -E- I TIME I TINE M OF I AL' :E- TLME 111.tE <br />r OF 1 M1.E. TIME I TIME N OF I ��LL <br />IDAT- I lNE I UU7' HQUI�S f DaTE !n I U4 P IHUU ►:S' r+G'_ dRTE ! l� OU' IHUUKS' aCi DATE !� U.!T IHOUkS ACE <br />i <br />I I I <br />i i Illl i!il il, <br />Iljj II Ilil <br />ill <br />i III III IIII <br />-T-T7 <br />Signature Date lelepnone Numoer <br />"Enter Comments on Back of Card" <br />