Rev. Form BR (04/2014)
By typing a name in this field, the signatory acknowledges that this entry constitutes
in every way, use, or aspect, his or her legally binding signature.
Name/Title/Telephone Number of Individual Filing the Form. Enter the name, title,
and telephone number of the individual filing the form.
Email Address.
Enter the email address of the individual filing this Form BR. This field is optional.
Date. Enter the month, day, and year that the form is being signed. Future dates
may not be entered in this section.
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