1987/2007 (20)If this certificate is no longer valid accordrn., to the above guidelines and the business referenced in box "1 a "continues t
named on a permit, license or contract issue-d by the certificate holder, the business must provide the certificate holder ether
with a new certifzc:~ate or other authorized ~!~~oof the business is complying with the mandatory coverage requirements o the
New York State Workers 'Compensation Ln ~ ~ f
Under Penalty al' perjury, I ePrt~f.; ~ti.,+ T ___ _
Wappingers Falls, NY 12590
c/o First Cardinal Corporation E~
10 British American Blvd ~r r+~,v
Latham, NY 12110-1415 GV
This certifies that the business refe ner ced :!!rove;n box "la" is complying with the
York State Workers' Com»er,aar;.,,, r .....
112004