or's Signature irlitplizer's Name & Eat Stamp Authorizer's Signature :ient/Caller Name: c.ilt Telephone. Back Name. -TA 'T YOUNG I - back Signah.tre: Back Date/Time CI btaincd 0 1 '.r -ed L. N. . oplicablc CMS/Global Hold Approval Not Applicable . DDA 0% -.:,.}ra et Approval EFTA01591713