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SERVICE PROVIDER:Please fill in the spaces and sign in the box appropriate for your business <br /> entity. <br /> Corporation I .-�-' <br /> Full Legal Name mal rya°�{ I$ !('S" `t4d 1lfr �on Ai1vt�, <br /> Signature: /..# <br /> Name of Signer: er <br /> j.' We_ei)//evy, <br /> Title of Signer: PIP'S P <br /> Partnership <br /> Full Legal Name: <br /> Signature: ,Partner <br /> Name of Signer: <br /> Sole Proprietor <br /> Signature: ,Sole Proprietor <br /> Name: <br /> Limited Liability Company <br /> Full Legal Name <br /> Signature: ,Managing Member <br /> Name of Signer: <br /> Page 3 of 4 <br /> Standard Document Approved 4.22.14/Office of City Attorney <br />