!"#$%&
'()*+,
-./L/0123, 45
678%&9
<=%&
#$%&'()*+,-./0123456789 :;<=>?@ABCD@3E9FG@2H9I JK2LMNOPQR1S3TUVWSXYZ[ \]@23M
eAOP@23@TM3! "M#$23@A^Z_@\%1& z'^()*+M,]o'*23@-./ 01M
A^Z_@`abcd`Sefg@23hij k1l3mno^p23qrst@udvwx 5yzVW{|}S~Nefg23@h, ,,S...`a=Z^SMS3z<OEpfg 23sZ@@`'"TU"@--" ~1STMs...]>oe="Z_Qzfg9Y " U@O1<OE"U@9"@`'M
efy23@1Sf"Qfg ...h`a-@M
:;#$%&
^z1]>oe=,,e\eS] @S3UQS@23M
23ud1"e`a R1o@M:1 OE`a3Z_Qz@23M# A1...]>@Z=1 90%@3Q,@231s TUo`'@3EMXKJz1 23e@`atMo^1 @`a"dloe Z@231oAtudM
>?@%& / A@BC
2S,,}o23`3lps4M&3 ,,S5B678lT9:1TMsRS( )^;@A<Mo23eZMo 23=>x
?: @7 TMC; EF J
53E AB; DE ?G HaHE
]e6@9...6@IJ1o23dfy KLM
DEF%&
o23TM5}B`'M&MzTMNO2 31zSTMs&P}OEQA`'IaKoe =MTMNO23=>x
R S #$ X+YZ ^_ bbbc
78 / TU VW 4[\] :[`a c[
!"
DOL-4435 CH (06/01)
MN`a%&
o23pdAe`'I`'*fstM`'s t23GB6\gh?@1iiTj97 89`'Ik&DlMmh5;23/TMN O23no1e`'st23Zd`M o23=>x
pmbqrst w'b w'{z r~ j
uv# x[yz #|}z w'bqr ,
bc#$%&
...2A*+=9S@23x
5;23/^;'1TMNO231s`'st 23M...62A*=,,9...'1^ zo23M
...Slhfg@231l'h^S zo231,A<S5{OE,,oe`' r1/S@23...Z3?OE`M
de$Wf
S'3l,S@3EoAud1& TM3""S'3<OE`'MiSh,fg @1S--W39~&
GHIJwww.dol.state.ga.us
KL$MNOP " QRSTUVWXYZ[\]^_