Qme Form 106 - Request For Qme Panel Under Labor Code Form Page 3
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4Declaration of Service
I declare that I am a resident of or employed in the county where the mailing took place. I am over the age of
eighteen years and I am not a party to this case, my business or residence address is:
On
, I served this QME 106 form, the original, or a true and correct copy of the original, which
is attached, on each of the persons or firms named below, by placing it in a sealed envelope, addressed to the person
or firm named below, and by:
A
depositing the sealed envelope with the U. S. Postal Service with the postage fully prepaid.
placing the sealed envelope for collection and mailing following our ordinary business practices. I am readily familiar
with this business’s practice for collecting and processing correspondence for mailing. On the same day that
B
correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the U. S.
Postal Service in a sealed envelope with postage fully prepaid.
placing the sealed envelope for collection and overnight delivery at an office or a regularly utilized drop box of the
C
overnight delivery carrier.
placing the sealed envelope for pick up by a professional messenger service for service. (Messenger must return to
D
you a completed declaration of personal service.)
E
personally delivering the sealed envelope to the person or firm named below at the address shown below.
Method of
Person or firm served
Street Address :
Service
City:
State
Zip Code:
Person or firm served
Method of
Street Address :
Service
City:
State
Zip Code:
Person or firm served
Street Address :
Method of
Service
City:
State
Zip Code:
Person or firm served
Street Address :
Method of
Service
City:
State
Zip Code:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
at
, California.
Type or print name
Signature _____________________________________________
QME Form 106 (rev. 9/2015)
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