ࡱ                >  	                                          	            "   bjbj<<                  	 3  ^ ^       3                                                                                                                               8   Q  d     $        0           (                         !  D  #  $  ^/     `/      `/      `/      `/      `/      `/      1    3     `/  u                         $                                 $     %     `/      %                                    /     %      %      %      %  ^     R                     ^/              %                                                      $      ^/              %      %  :   *  t     "                                                                 z+                      oL              e%     +  
           +    /  0   0      (+  R   4      %      4     z+      %                                                              z+                           +                                                                                                                                                                                             $      $      $                                                                                                                                                                                                                                                                                                                      W  :      	                                                                                                                                                                                                                                                                                                                                                                                                                                  SECURE REQUEST FOR SERVICESFor confidential transmission, please complete, then print and mail or fax (address below):Click by all that apply- FORMCHECKBOX   Vocational Evaluation        FORMCHECKBOX   Rehabilitation Counseling  FORMCHECKBOX   Occupational Research       FORMCHECKBOX   Career Guidance                 FORMCHECKBOX   Job Placement                     FORMCHECKBOX   On-site Job Analysis          FORMCHECKBOX   Return-to-work Planning   FORMCHECKBOX   Case Management             FORMCHECKBOX   Other                                 Case Type-  FORMCHECKBOX   Disability Insurance            FORMCHECKBOX   Self-Insured                         FORMCHECKBOX   Workers Compensation      FORMCHECKBOX   Personal Injury                   FORMCHECKBOX   Other                                 CASE INSTRUCTIONS AND SCHEDULE- (active form fields): FORMTEXT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        T o d a y  s   D a t e :      F O R M T E X T             C U S T O M E R :  C a s e   C o n t a c t :      F O R M T E X T                 C o m p a n y :      F O R M T E X T             M a i l i n g   A d d r e s s :      F O R M T E X T             C i t y :      F O R M T E X T            S t a t e :      F O R M T E X T                                            Z i p :      F O R M T E X T             P h o n e :      F O R M T E X T            F a x :      F O R M T E X T             E m a i l :      F O R M T E X T            W e b :      F O R M T E X T             C L A I M A N T :  F u l l   N a m e :      F O R M T E X T             M a i l i n g   A d d r e s s :      F O R M T E X T             C i t y :      F O R M T E X T            S t a t e :      F O R M T E X T            Z i p :      F O R M T E X T             P h o n e :      F O R M T E X T            2 n d   P h o n e :      F O R M T E X T             C l a i m # :      F O R M T E X T            S S N :      F O R M T E X T             D O B :      F O R M T E X T            D O I :      F O R M T E X T            A W W :      F O R M T E X T             O c c u p a t i o n :      F O R M T E X T            A n y   O c c   S t a r t s :      F O R M T E X T             I n j u r y /   I l l n e s s :      F O R M T E X T         F O R M T E X T             A T T E N D I N G   P H Y S I C I A N :  D r . :      F O R M T E X T             S p e c i a l t y :      F O R M T E X T             P r a c t i c e   N a m e :      F O R M T E X T             M a i l i n g   A d d r e s s :      F O R M T E X T             C i t y :      F O R M T E X T            S t a t e :      F O R M T E X T            Z i p :      F O R M T E X T             P h o n e :      F O R M T E X T            F a x :      F O R M T E X T             E m a i l :      F O R M T E X T            W e b :      F O R M T E X T             C o o r d i n a t o r :      F O R M T E X T             E M P L O Y E R :  E m p l o y e r   C o n t a c t :      F O R M T E X T             C o m p a n y :      F O R M T E X T             M a i l i n g   A d d r e s s :      F O R M T E X T             C i t y :      F O R M T E X T            S t a t e :      F O R M T E X T            Z i p :      F O R M T E X T             P h o n e :      F O R M T E X T            F a x :      F O R M T E X T             E m a i l :      F O R M T E X T            W e b :      F O R M T E X T             A T T O R N E Y /   O T H E R :  C a s e   C o n t a c t :      F O R M T E X T             C o m p a n y :      F O R M T E X T             M a i l i n g   A d d r e s s :      F O R M T E X T             C i t y :      F O R M T E X T            S t a t e :      F O R M T E X T            Z i p :      F O R M T E X T             P h o n e :      F O R M T E X T            F a x :      F O R M T E X T             E m a i l :      F O R M T E X T            W e b :      F O R M T E X T              R E C O R D S  T o   p r o v i d e   q u a l i t y   s e r v i c e s ,   p l e a s e   s u b m i t   t h i s   c o m p l e t e d   f o r m ,   w i t h   p e r t i n e n t   r e c o r d s   a t   t h e   s a m e   t i m e   a s   t h i s   r e f e r r a l   t o :   R .   B r a d   C o f f e y, M.Ed., M.B.A.Re-Employment Resources, L.C.1100 NW Loop 410, Suite 700San Antonio, TX 78213FAX: 1-877-875-4765Relevant medical and psychological records from attending and consulting physicians, and other treatment providers and facilities.  Special attention to functional capacity evaluations (FCE) and/or physical/ mental capacities assessments.For litigated cases: Depositions, interrogatories, reports and other correspondences from any parties that pertain to the injury(s) and/or vocational aspects of the case.For litigated cases: Tax returns and other documentation of pre- and post-injury wages and earnings.School records, testing and assessment results, and/or any other vocationally relevant information.Thank you !                                                                                                                                                                                                                                                                                                                                                                                                     Page  PAGE 1 of  NUMPAGES 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            	  	  	   	  !	  /	  0	  1	  S	  T	  b	  c	  d	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
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t  0                              $6                          4   4 
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        yrh    h>	 h>	 5>* hP h>	  j    h>	 UmH nH u j  h>	 Uh1 h>	  h>	 5>* h{ h>	 5>* j  h>	 Uj  h>	 Uj  h>	 Uj%  h>	 Uj  h>	 Uh>	  j    h>	 UhVs h>	 5h>	 h>	 CJ aJ (e  f      Z                ~            g            P            P                                                                                       $ $If   gd>	 l                  $If   ]gd>	 l                   $ gd>	 x  kd  $$If   l             0 $                  
t  0                              $6                          4   4 
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t  0                                              4   4 
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t  0                                              4   4 
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        $  @  B  V  X  Z  d  f                                        &  (  8  :  N  P  R  \  ^                  j  h>	 Uj  h>	 Uj3  h>	 UjH  h>	 Uj]
  h>	 Ujr	  h>	 Uh{ h>	 5>* h>	 h>	 5>* j    h>	 UmH nH u j  h>	 Uj    h>	 Uh>	 4  $  l  n                            z                                                                                                                                                                                                    e  kd	  $$If   l              $ $                
t  0                              $6              4   4 
l a      p& $If   gd>	 l                   p& gd>	                                                   e  kd  $$If   l              $ $                
t  0                              $6              4   4 
l a      p& $If   gd>	 l               e  kd
  $$If   l              $ $                
t  0                              $6              4   4 
l a     *                                                ]                                                                                                                      kd  $$If   l             F $ ~                                  
                
t  0                              $6                                      4   4 
l a      p& $If   gd>	 l                                    
          ,  .  B  D  F  P  R  ^  `  t  v  x                                   "  $  4  6  J  L  N  X  Z  j  l                j  h>	 Uj  h>	 Uj  h>	 Uh{ h>	 5>* j  h>	 Uj  h>	 Uj  h>	 Uj    h>	 UmH nH u j2  h>	 Uj    h>	 Uh>	 6    T                p            p                                                                                                                                                                                         p& $If   gd>	 l               x  kd  $$If   l             0 $ ~                 ~                
t  0                              $6                          4   4 
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t  0                              $6                          4   4 
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t  0                                6              4   4 
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t  0                                6              4   4 
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t  0                                6                                      4   4 
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t  0                                6                          4   4 
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t  0                                6                          4   4 
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      ,  .  0  :  <  X  Z  n  p  r  |  ~                        
       .  2  \  f  h  |  ~                        } j]  h>	 Uh>	 h>	 5>* hy h>	  jp  h>	 Uh{ h>	 5>* j  h>	 Uj  h>	 Uj  h>	 Uj  h>	 Uj  h>	 Uh>	  j    h>	 UmH nH u j    h>	 U 1>  @      t            ]            ]                                                                                                                                                   p& $If   gd>	 l                 kd  $$If   l             F $ x                 x                 x                
t  0                                6                                      4   4 
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t  0                                6                          4   4 
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t  0                                6              4   4 
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t  0                                6              4   4 
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t  0                                6              4   4 
l a                         :  <  P  R  T  ^  `  b  d  p  r                                                     &  (  *  4  6  8  B  D  X   j-"  h>	 Uj!  h>	 Uj   h>	 UhtK h>	  j(   h>	 Uj;  h>	 Uhy h>	  j    h>	 UmH nH u jJ  h>	 Uj    h>	 Uh>	  h>	 h>	 5>*7      b                                                                                                                                                                                                                                                 g  kd  $$If   l             F  $ h%                
t  0                                6              4   4 
l a      p& $If   gd>	 l                b  d                                                                                                                                                                                                                                                           p& $If   gd>	 l               e  kd  $$If   l              $ h%                
t  0                                6              4   4 
l a        8  j  t            ]            ]                                                                                                                                                   p& $If   gd>	 l                 kd!  $$If   l             F H$                                   4                
t  0                                6                                      4   4 
l a   X  Z  \  f  h  j  l  z  |                                        
          .  R  T  h  j  l  v  x  z  |                        ɾɳɨ͞ɓɈ   j&  h>	 Uj%  h>	 Uh{ h>	 5>* j%  h>	 Uj$  h>	 Uj#  h>	 Uh>	  h>	 h>	 5>* hy h>	  j    h>	 UmH nH u j    h>	 Uj"  h>	 U 5j  l                  p            p                                                                                                                                                                                         p& $If   gd>	 l               x  kd#  $$If   l             0 H$                                  
t  0                                6                          4   4 
l a                     p                                                                                                                                                                                                          p& $If   gd>	 l               x  kd$  $$If   l             0 H$                                  
t  0                                6                          4   4 
l a       .  z                          z                                                                                                                                                                                                             p& $If   gd>	 l                   p& gd>	 e  kdy%  $$If   l              $ h%                
t  0                                6              4   4 
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t  0                                6              4   4 
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t  0                                6              4   4 
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        0  2     j',  h>	 Uj2+  h>	 Uj*  h>	 Uj)  h>	 Uj-)  h>	 Uj(  h>	 Uh>	 h>	 5>* hy h>	  j    h>	 UmH nH u j    h>	 Uj'  h>	 Uh>	 5      8  n                                                                                                                                                                                                                                             e  kd@(  $$If   l              $ h%                
t  0                                6              4   4 
l a      p& $If   gd>	 l                      
  t            ]            ]                                                                                                                                                   p& $If   gd>	 l                 kd*  $$If   l             F H$                                   4                
t  0                                6                                      4   4 
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    B  t              p            p                                                                                                                                                                                         p& $If   gd>	 l               x  kd+  $$If   l             0 H$                                  
t  0                                6                          4   4 
l a   2  4  >  @  B  L  N  b  d  f  p  r  t  v                                  
          <  >  R  T  V  `  b  d  f  r  t          ɿޭޚވ} jQ0  h>	 Ujd/  h>	 Uh,e h>	  j.  h>	 Uh>	 h>	 5j-  h>	 Uh>	 5>* h{ h>	 5>* h>	 h>	 5>* j,  h>	 Uh>	  hy h>	  j    h>	 UmH nH u j    h>	 U 1t  v                  |            b                                                                                                                                                            $ p& $If   a$gd>	 l                   p& gd>	 z  kd-  $$If   l             P 0 H$                                  
t  0                                6                          4   4 
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t  0                                6              4   4 
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t  0                                6              4   4 
l a   d  f                                                                                                                                                                                                                                                   $ p& $If   a$gd>	 l               e  kd/  $$If   l              $ h%                
t  0                                6              4   4 
l a                                                (  *  ,  6  8  :  D  F  Z  \  ^  h  j  l  n  |  ~                                              	h>	 5j74  h>	 Uj3  h>	 Uj2  h>	 UjV2  h>	 Uh>	 h>	 5j=1  h>	 Uj    h>	 UmH nH u j0  h>	 Uh>	  h,e h>	  j    h>	 U 6    :  l  t            Z            Z                                                                                                                                            $ p& $If   a$gd>	 l                 kd1  $$If   l             F H$                                   4                
t  0                                6                                      4   4 
l a   l  n                  m            m                                                                                                                                                                                  $ p& $If   a$gd>	 l               x  kdB3  $$If   l             0 H$                                  
t  0                                6                          4   4 
l a                 /  K  a  u  v              {            o            f            f            a            a            a            a            f            f                  d      p& gd>	    $ p& a$gd>	    $ p& a$gd>	 x  kd4  $$If   l             0 H$                                  
t  0                                6                          4   4 
l a             `  a     k"  l"  n"  o"  q"  r"  t"  u"  w"  x"  "  "  "  "  "  "  "  "  "  "  "  "  "  "                                                                                                                                                                                                                       j,5  h>	 Uj    h>	 Uh>	 mH nH uh l h>	 mHsH h>	 mHsH h>	  	h>	 >*h>	 5>* h{ h>	 5>*v  e     u         k"  m"  n"  p"  q"  s"  t"  v"  w"  y"  z"  "  "  "  "  "  "                                                                                                                                                                                                                                                                                           d    $a$gd>	   ^gd>	        p& d  gd>	    
& F 
hp&     ^  `  gd>	  "  "                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   p& d  gd>	  1 0 &P 1F:p>	 / =!"#	$%                                                                                                                                                                                                                                                                                                                                                                                                                                                                               t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         t   D                                                               e     C h e c k 3                         t   D                                                               e     C h e c k 4                         t   D                                                               e     C h e c k 5                         t   D                                                               e     C h e c k 6                         t   D                                                               e     C h e c k 7                         t   D                                                               e     C h e c k 8                         t   D                                                               e     C h e c k 9                          $$If     !v h5 5#v #v:V l 
t  0                              $65 5/      v   D                                                               e     C h e c k 1 0                         v   D                                                               e     C h e c k 1 1                         v   D                                                               e     C h e c k 1 2                         v   D                                                               e     C h e c k 1 3                         v   D                                                               e     C h e c k 1 4                          $$If     !v h5 5#v #v:V l 
t  0                              $65 5/      t   D                                                                 '   T e x t 1                           v $$If     !v h5 $#v $:V l 
t  0                                5 $v   D                                                                     T e x t 5 8                           v $$If     !v h5 $#v $:V l F 
t  0                                5 $t   D                                                                 2    T e x t 2                           u $$If     !v h5 $#v $:V l 
t  0                              $65 $t   D                                                                 2    T e x t 3                           u $$If     !v h5 $#v $:V l 
t  0                              $65 $t   D                                                                 2    T e x t 4                           u $$If     !v h5 $#v $:V l 
t  0                              $65 $t   D                                                                     T e x t 5                           t   D                                                                     T e x t 6                           t   D                                                                     T e x t 7                            $$If     !v h5 ~55
#v ~#v#v
:V l 
t  0                              $65 ~55
t   D                                                                     T e x t 8                           t   D                                                                     T e x t 9                           } $$If     !v h5 ~5~#v ~:V l 
t  0                              $65 ~v   D                                                                     T e x t 1 0                           v   D                                                                     T e x t 1 1                           } $$If     !v h5 ~5~#v ~:V l 
t  0                              $65 ~v   D                                                                 2    T e x t 1 2                           u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%v   D                                                                 2    T e x t 1 3                           u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%v   D                                                                     T e x t 1 4                           v   D                                                                     T e x t 1 5                           v   D                                                                     T e x t 1 6                            $$If     !v h5 554#v #v#v4:V l 
t  0                                65 554v   D                                                                     T e x t 1 7                           v   D                                                                     T e x t 1 8                           } $$If     !v h5 5#v :V l 
t  0                                65 v   D                                                                     T e x t 1 9                           v   D                                                                     T e x t 2 0                           } $$If     !v h5 5#v :V l 
t  0                                65 v   D                                                                     T e x t 2 1                           v   D                                                                     T e x t 2 2                           v   D                                                                     T e x t 2 3                            $$If     !v h5 x5x5x#v x:V l 
t  0                                65 xv   D                                                                     T e x t 2 4                           v   D                                                                     T e x t 2 5                           } $$If     !v h5 5#v :V l 
t  0                                65 v   D                                                                 F    T e x t 2 6                           v   D                                                                 A    T e x t 2 6                           u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%v   D                                                                 2    T e x t 2 7                           u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%v   D                                                                 2    T e x t 2 8                           u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%v   D                                                                 2    T e x t 2 9                           y $$If     !v h5 h%#v h%:V l F 
t  0                                65 h%v   D                                                                 2    T e x t 3 0                           u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%v   D                                                                     T e x t 3 1                           v   D                                                                     T e x t 3 2                           v   D                                                                     T e x t 3 3                            $$If     !v h5 554#v #v#v4:V l 
t  0                                65 554v   D                                                                     T e x t 3 4                           v   D                                                                     T e x t 3 5                           } $$If     !v h5 5#v :V l 
t  0                                65 v   D                                                                     T e x t 3 6                           v   D                                                                     T e x t 3 7                           } $$If     !v h5 5#v :V l 
t  0                                65 v   D                                                                 2    T e x t 3 8                           u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%v   D                                                                 2    T e x t 3 9                           u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%v   D                                                                 2    T e x t 4 0                           u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%v   D                                                                 2    T e x t 4 1                           u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%v   D                                                                     T e x t 4 2                           v   D                                                                     T e x t 4 3                           v   D                                                                     T e x t 4 4                            $$If     !v h5 554#v #v#v4:V l 
t  0                                65 554v   D                                                                     T e x t 4 5                           v   D                                                                     T e x t 4 6                           } $$If     !v h5 5#v :V l 
t  0                                65 v   D                                                                     T e x t 4 7                           v   D                                                                     T e x t 4 8                            $$If     !v h5 5#v :V l P 
t  0                                65 v   D                                                                 2    T e x t 4 9                           u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%j   D                                                                 2                               u $$If     !v h5 h%#v h%:V l 
t  0                                65 h%v   D                                                                 2    T e x t 5 0                           u $$If     !v h5 h%#v h%:V l 
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F<з:B *> ul0GĜp͸z8vd2gpoyW-&68m!D-JuWfHXbO`"S&e+EAs^|UI?pbҞMT?ss"N:3jK=IFaS^6a:o$n/hqi0`/5q/CiIب@MGc]WdF% ̠!#!l~A@.Z,>[ۗ$PɲkfoeTգ"	f6\.2f*{e~`Gǅ[_'uEw"-EaqƔOmgsNl5P6ۼ:6#ĝA)8<vQk}j06 >H+s:R#1`=ϒay1jR#'%{0`4Kq=e0ÀH➔ʹBڏ4^qM6 lԡ\N#9; au$M`y"+Q&Nކ}@gaGDANX@gaUۈ{N;N1lgv+:Ymq6'_huäa2F+$,c-L(bi7MM]gX1Z$&1I8ȩloqkĽB ڊqqDmvW[g!?{K@Ke:7^%qQ{8icwl0Zeךa30@|pMDmw׵A;yofU&ɺ ܷDhu0О c>K+VwS۳۽_D` dXmV;SD0n0(sY;,G+c{A]5lFYm.<Ym6tYm`P}{ވ{d;ź,IYncckh0Ā{4"Q^k8GTc9mb~7@`{;mDwմ#jVx/Àa00^#$ּ{.ˈك&wÀa0`0א3XƭêZy	i֜qlj	0`0:FkL=y8upXѴOJEn0`0#u"7rXHM"D}9Àa0`0FD;EGٺ[c!3plv6Àa0^GE'i^QOyv@=sÀa0`יn/ꈊ<GT#46AY[Àa0qo qT
qB-Qmha4Àa0 e3*f* ?Α\i|1İM@gc{IϻMd6q[Àa0`Ľ=*'Yr%7nm0`04Fܛ !)aUQ#%W2$ɻa0`<qo"6d]㽛#jNÀa0`Hb{w:nm[#YٛBb0c{"V"ٷִ[Àa0`h&qoB-*ѴOfqoR6dfe0`0Fܛ'w$0n08qobn a0`0#FMb0Àa00	;HYJÀa0`0ǀw#6Àa0`hwCyD.    IENDB`                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      6  6  6  6  6  6  6  6  6  2                     0  @  P  `  p                   2  (         0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p      8  X        V  ~     _HmH	nH	sH	tH	    @  ` @   94    N o r m a l       CJ _HaJ mH	sH	tH	                  D A  D          D e f a u l t   P a r a g r a p h   F o n t     V i@ V          T a b l e   N o r m a l     :V   4   4 
l a      ( k  (           N o   L i s t         H    H   L    B a l l o o n   T e x t      CJ OJ QJ ^J aJ 4 @ 4   ]    H e a d e r      !   4  @ 4   ]    F o o t e r      !   t @ #t    94   
 T a b l e   G r i d   A :V 0                                 a        PK     !         [Content_Types].xmlj0u$Nwc$ans@8JbVKS(.Y$8<UzZ!Y8*yJ	+}M9LJ)UgO$)I2#3thXOO.Wv`Dڵz>MVgLYS]"(U֎_o[gv;
f>KH|;\XV!]օ	Oȥsh]Hg3߶   PK     ! ֧   6     _rels/.relsj0}Q%v/C/} (h"O
= C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/Seе   PK     ! ky         theme/theme/themeManager.xmlM
 @}w7c(Ebˮ CAǠҟ7՛KY,e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+&
8   PK     ! \       theme/theme/theme1.xmlYOoE#F{o'NDuر	i-q;N3'G$$DAč*iEP~wq 4;{o?g^;N:$BR6 4Mvsi-@R4mUb V*XX!cyg$w.Q"@oWL 8*Bycjđ0蠦r,[LC9VbX*x_yuoBL͐u_.DKfN1엓:+ۥ~`jn[Z p֖zg,tV@bW/Oټl6Ws[R?S֒7 _כ[֪7 _w]ŌShN'^Bxk _[dC]zOլ\K=.: @MgdCf/ o\ycB95B24SCEL|gO'<yV#aU7#_<܏U/OP>sקo>W=n#p̰ZN|ӪV:8z1f؃k;ڇcp7#z8]Y/\{t\}}spķ=ʠoRVL3N(B<|ݥuK>P.EMLhɦM .co;əmr"*0#̡=<R8U	U3;aז
"=$vDo%סuþƉtW$a4(F{\ܭqpߡ	6:&MD	KhNNhv@7ݹvW<6- W	;,"o~ƣt@O/<o[ۖ[zNz+]bENf3rCMu"3CR~}62Hp!Uq7lkV2Dp3^te+`jGvxYRYmYL;\):մQsV3VV1vK6a`,\OHyko'D֑GĆY3+R\@JyBw>6Kր0i1;$P0!YݩjbiXJB5IgAФ޲a6{P	g֢)҉-Ìq8RmcWyXg/u]6Q_Ê5H
Z2PU]Ǽ"GGFbCSOD%,p6ޚwq̲R_gJS<kq芿(Wi?sE/p_tBzm\Cbvw@U*./ȡ֜akjXmdjcU\ɨ2f!a=WuPnItyzR7Kzb:[_Y/Ȫ#dT/Y^ӄyZk;֔K+qiadp]?Q2aA/=wdnW=v&Vew>bj9)ed(w:/ak;6jAq11_xzG~F<:ɮ>O&kNa4dht\?J&l	O٠NRpwhpse)tp)af]
27n}mk]\S,+a2g^Az)˙>E
G鿰L7)'    PK     ! ѐ     '   theme/theme/_rels/themeManager.xml.relsM
0wooӺ&݈Э56?$Q,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{ P8g/]QAsم(#L[    PK-      !                       [Content_Types].xmlPK-      ! ֧   6               /  _rels/.relsPK-      ! ky                     theme/theme/themeManager.xmlPK-      ! \                   theme/theme/theme1.xmlPK-      ! ѐ     '             
  theme/theme/_rels/themeManager.xml.relsPK      ]      <?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<a:clrMap xmlns:a="http://schemas.openxmlformats.org/drawingml/2006/main" bg1="lt1" tx1="dk1" bg2="lt2" tx2="dk2" accent1="accent1" accent2="accent2" accent3="accent3" accent4="accent4" accent5="accent5" accent6="accent6" hlink="hlink" folHlink="folHlink"/>          K           P              P                  P                                K                     	                  2   2   2   5      P
            X    2      "               %   (   -   1   6   :   ?   C      P
  e                (  :    >    0      b     j      z      
  t      d    l    v  "  "                       !   "   #   $   &   '   )   *   +   ,   .   /   0   2   3   4   5   7   8   9   ;   <   =   >   @   A   B   D   E                       0  S  c                %  ]  m              *  :          (  .  I  U  [  i  u  {                           
      #  /  5  ?  K  Q  X  d  j                              	      %  2  >  D  O  [  a  h  t  z                                  +  ,  -  9  ?  \  h  n  |                          	  	  	  !	  '	  1	  =	  C	  J	  V	  \	  f	  r	  x	  	  	  	  	  	  	  	  	  	  	  	  
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        !  -  3  G  S  Y  b  n  t  }                                     K  G$G$G$G$G$G$G$G$G$G$G$G$G$G$FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF         "   -   /   5   !                                  ?    b $   p6`1_9 D          b $   S%\<̕4ԍgȧ           2 $   n5]QLR2 w          @                            0    (    	                    
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        S              	   ?           H              0    (    	                    
         K  H    C h e c k 1  C h e c k 2  C h e c k 3  C h e c k 4  C h e c k 5  C h e c k 6  C h e c k 7  C h e c k 8  C h e c k 9  C h e c k 1 0  C h e c k 1 1  C h e c k 1 2  C h e c k 1 3  C h e c k 1 4  T e x t 1  T e x t 5 8  T e x t 2  T e x t 3  T e x t 4  T e x t 5  T e x t 6  T e x t 7  T e x t 8  T e x t 9  T e x t 1 0  T e x t 1 1  T e x t 1 2  T e x t 1 3  T e x t 1 4  T e x t 1 5  T e x t 1 6  T e x t 1 7  T e x t 1 8  T e x t 1 9  T e x t 2 0  T e x t 2 1  T e x t 2 2  T e x t 2 3  T e x t 2 4  T e x t 2 5  T e x t 2 6  T e x t 2 7  T e x t 2 8  T e x t 2 9  T e x t 3 0  T e x t 3 1  T e x t 3 2  T e x t 3 3  T e x t 3 4  T e x t 3 5  T e x t 3 6  T e x t 3 7  T e x t 3 8  T e x t 3 9  T e x t 4 0  T e x t 4 1  T e x t 4 2  T e x t 4 3  T e x t 4 4  T e x t 4 5  T e x t 4 6  T e x t 4 7  T e x t 4 8  T e x t 4 9  T e x t 5 0  T e x t 5 1  T e x t 5 2  T e x t 5 3  T e x t 5 4  T e x t 5 5  T e x t 5 6  T e x t 5 7          !  T          ^        +      I  i          
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  &  E  b  {            @  o          	  (	  D	  ]	  y	  	  	  	  
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                                                                      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   0   1   2   3   4   5   6   7   8   9   :   ;   <   =   >   ?   @   A   B   C   D   E   F   H   I   J   K   L   M   N   O   P   Q   R   S   T   U   V   W   X   Y   Z   [   \   ]   ^   _   `   a   b   c   d   e   f   g   h   i   j   k   l   m   n   o   p   q   r   s   t   u   v   w   x   y   z   {   |   }   ~                                                                                                                                                                                                                                                                                             R o o t   E n t r y                                                 	           F            RN          D a t a                                                         
                                     G         1 T a b l e                                                                                                 4      W o r d D o c u m e n t                                                                                        3       S u m m a r y I n f o r m a t i o n                           (                                                D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                                   C o m p O b j                                                                                                `       O b j e c t P o o l                                                                   2RN2RN                  	           F    Microsoft Word 97-2004 Document NB6W   Word.Document.8                                                                                                                                                                                                                                                                                                                                                                                                                                     
