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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 /> Date: <br /> `` , y <br /> Limited \ �tJtl+ . WAR rAAy3 �,O t�SiI�H!1D rV C► 0,01.1,1115 Q.(It <br /> Liability <br /> [Serkice Provider's Complete Legal Name] <br /> Company a Washington limited liability company ST1 ( t. <br /> Type <br /> T e t t err, k � � I. � kVA') <br /> Managing Memb <br /> Date: /a ) /1 <br /> Page 11 <br /> Wendy Warman Clinical Supervision PSA <br />