The Company
ACCEPTANCE OF APPOINTMENT
AS PRIVACY OFFICER
Name of appointee, having been duly appointed by the Officers of the Company to serve as the privacy officer as required under the Health Insurance Portability and Accountability Act of the Company Flexible Benefits Plan, and name of appointee, having been duly appointed by the Officers of the Company to serve as the privacy officer as required under the Health Insurance Portability and Accountability Act of the Company Health Plan, hereby accept such appointment and agree to serve as such with all responsibilities and obligations attendant thereto.

ATTEST:
privacy officer
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Title
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ATTEST:
Officer
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Title
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