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Section : I declare that
Domain : Human Resource Management
Classification : Not Identified

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 the information provided in this claim form is true and correct to the best of my knowledge.
 I understand that making a false declaration is an offence. I authorise and direct the Fair Work Ombudsman to pay the money claimed, and any additional money the Fair Work Ombudsman may identify as belonging to me, in the way I have directed in this form (by direct deposit or cheque). Claimant's name: Claimant's signature: Date / / 117