SIGNATURE LINE. On behalf of , ("Professional Group"), I hereby tender this Certificate of Participation in Healthways WholeHealth Networks, Inc ("HWHN") upon the terms and conditions set forth in this HWHN Participating Institutional/Group Agreement. With this Certificate, our Professional Group agrees the Practitioners herein named will serve as Participating Practitioner members of HWHN for Affinity Programs, and hereby specifically authorizes and appoints HWHN to act on our behalf to contract for the provision of discounted cash services to eligible members of HWHN Client Groups via HWHN Affinity Programs. FACILITY INFORMATION (please use a separate sheet for additional locations) Primary Location: Clinic Name: Address: City, State, Zip: Phone: Office Fax: Office Contact: Title: Secondary Location: Clinic Name: Address: City, State, Zip: Phone: Office Fax: Office Contact: Title: Website Address: E-Mail What non-English languages are spoken at your facility? Website Would you like your website published on your profile? yes no Average Price Range of Services $ to $ DEFINITIONS
SIGNATURE LINE. Employee/Agent/Person Collecting Equipment hereby guarantees payment to Axis Torque Ltd. of the total liability which said company has incurred to Axis Torque Ltd. for the lease of equipment, goods and services. BACK SIDE OF CONTRACT By this lease and in consideration of the statements on the reverse side hereof and the following agreements, limitations and conditions, Axis Torque Ltd., hereinafter called the “Lessor”, leases unto the person, firm or corporation signing this lease as Lessee, hereinafter called “Lessee” that certain personal property hereinafter called equipment, described on the reverse side hereof.
SIGNATURE LINE. If this application is approved, the conditions on the prior page of this application will be observed. The above named applicant/ organization agrees to assume all responsibilities for damages, loss, or other liabilities arising from the use of the Church’s facilities. A $100.00 refundable deposit is required at the time of application. SIGNED: For Official Use Only Approved: Building Rental Liaison Total Rental Amount: Date: Deposit Amount Received: _ Date: RENTAL POLICY
