unt. ( - I eSC-23. Back Name : 1 (\_ \1°UN51 en) 1 /Jack Signarurc ..Il Back Date/- Tim. q 4 / 1, Q 1 /2:0 Hold Approval 1.4.a Applicablc • OvcrdrJaft Approval btained El Thtairiod CI I N, ,r Npplicable CMS/Global DDA ID: 036209145091380 DATE: 09/14/2012 16:14:00 Page 1 of 2 DID: 8887316607