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APPLICATION FOR MEMBERSHIP IN THE <br /> <br />NORTH CAROLINA ASSOCIATION OF COUNTY COb~IISSIONERS <br />JOINT RISK b~NAGEb~NT AGENCY WORKERS' COb~ENSATION FUND <br /> <br />We hereby formally apply for continuing membership in the <br />North Carolina Association of County Commissioners Joint <br />Risk Management Agency Workers' Compensation Fund pursuant <br />co the Interlocal Agreement entitled Interlocal Agreement <br />for a Group Self-Insurance Fund for Workers' Compensation <br />Risk Sharing. <br /> <br />Dated at this day of . <br /> , 19 <br /> <br /> County or Local Agency <br /> <br /> By: <br /> <br /> Title <br /> <br /> <br />