Discount Medical Plan Organization Application - Louisiana ...

NOTARIZATIONSTATE OFCOUNTY OR PARISH OFBEFORE ME, the undersigned authority personally appearedandwho, after being duly sworn, did depose and state that allinformation contained in this application and all attachments thereto is, to the best of his/her knowledge, true,complete and correct.Signature of Witness____________________________________________________Signature of Applicant or Authorized RepresentativePrinted Name of Witness____________________________________________________Printed Name and Title of Authorized RepresentativeSignature of Witness____________________________________________________Signature of Authorized Representative of ApplicantPrinted Name of Witness____________________________________________________Printed Name and Title of Authorized RepresentativeSWORN TO and subscribed before me this day of , 20 .____________________________________________________Signature of Notary____________________________________________________Printed Name of NotaryNOTARIAL SEALMy Commission Expires _______________________________APPLICATION TO ACT AS A DISCOUNT MEDICAL PLANPage 11 of 12(REV 10/2008)