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Campbell. Melynda (DES) <br />From: noreply@formstack.com <br />Sent: Tuesday, February 21, 201712:05 PM <br />To: OFM CI: Erickson, Paul (WaTech) <br />Subject: DES -Cert Ins Request Forml - Central Washington University <br />Self Insurance Form - Certificate of Liability Insurance <br />CERTIFICATE OF LIABILITY INSURANCE REQUEST FORM <br />Sent: Feb 21, 201712:05 PM <br />Form record ID: 306654964 <br />Copy and paste the string below into the Excel file <br />205 <br />CRT Central 400E Ellensbur West <br />99- g, Kittitas Ellensburg, <br />Washington University WA 98926 ToniBurveeburyeet u�GWIJ.E)3iJCounty 5th, WA 98926 <br />??? University Way Suite <br />108 <br />Your Agency <br />Agency Address <br />Your Name <br />Your Email <br />Your Phone <br />Outside Entity <br />"ATTN" Name <br />Certificate lfclder Email <br />Certificate Holder Address <br />Reason for Certificate <br />Central Washington University <br />400 E University Way <br />Ellensburg, WA 98926 <br />Toni Burvee <br />(509) 963-2335 <br />Kittitas County <br />205 West 5th, Suite 108 <br />Ellensburg, WA 98926 <br />Metric Bike Event <br />Date Certificate Needed Feb 28, 2017 <br />