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SERVICE PROVIDER: Please fill in the spaces and sign in the box appropriate for <br /> your business entity. <br /> Corporation <br /> [Service Provider's Complete Legal Name] <br /> By: <br /> Typed/Printed Name: <br /> Its: <br /> Date: <br /> Partnership <br /> (general) [Service Provider's Complete Legal Name] <br /> a Washington general partnership <br /> By: <br /> Typed/Printed Name: <br /> General Partner <br /> Date: <br /> Partnership <br /> (limited) [Service Provider's Complete Legal Name] <br /> a Washington limited partnership <br /> By: <br /> Typed/Printed Name: <br /> General Partner <br /> Date: <br /> Sole <br /> Proprietorship Typed/Printed Name: <br /> Sole Proprietor: <br /> �D1ate: <br /> Limited\f.)�Ck Wf\f`' rt GL,.� -/A+lp rJ 1'r ct AL(C,,I; S i"1,01 <br /> Liability [S ice Provider's Complete Legal Name] <br /> Company a Washington limited liability company <br /> t., <br /> B <br /> Type rinted Name. cd 1,00 L-\IMIXSt) <br /> Managing Memb r <br /> Date: (7)31 aj 16 <br /> Page 11 <br /> Wendy Warman Clinical Supervision PSA <br />