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<br />Authorization and Payment . <br />I hereby authorize WeDs Fargo Health Benefit Services to provide services based on the information provided within this application. <br />X <br />Signature of Company Representative Date <br />Broker Information (if you did not use an broker to establish this relationship, please skip this section) <br />Broker Name Allan T. Roth I B763~54~8898e) <br />Broker E-mail Address <br />al.roth@at-group.net <br />Wells Fargo Internal Use Only <br />Account # 58# Signed Documents Received: <br /> o Contract o Document o Fee Schedule <br /> o SWeep Agreement o Signers o Communications <br />Vendor # BC# Document Packet Sent On Live Data for Card (45 days): <br />Processor Relationship Manager <br />Approved By Approval Date <br /> <br />Web site: www.wfhbs.com <br />Phone: (866) 890-8309 <br /> <br />- <br /> <br />- <br /> <br />HSA-ERA <br />3/1512006 <br /> <br />CONFIDENTIAL ONCE COMPLETED AND RETURNED <br /> <br />/P() <br />