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12 <br />189822v4 <br /> MEDEXPRESS URGENT CARE <br /> MINNESOTA P.C. <br /> a ______________________________ <br /> <br /> <br /> By: ______________________________________ <br /> ____________________________ [print name] <br /> Its _________________________ <br /> <br /> <br /> <br /> <br /> <br />STATE OF MINNESOTA ) <br /> ( ss. <br />COUNTY OF ____________ ) <br /> <br /> The foregoing instrument was acknowledged before me this _______ day of <br />_________________, 20___, by ________________________, the __________________of <br />MEDEXPRESS URGENT CARE MINNESOTA P.C., a ___________________________, <br />on behalf of the _______________________. <br /> <br /> __________________________________________ <br /> Notary Public <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />DRAFTED BY: <br />Campbell, Knutson <br />Professional Association <br />Grand Oak Office Center I <br />860 Blue Gentian Road, Suite 290 <br />Eagan, Minnesota 55121 <br />Telephone: (651) 452-5000 <br />(JJJ) <br /> <br />