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FACILITY INFORMATION

Facility Name

Address

City

  State 

  Zip 

Phone

  Fax   

Tax ID  

 Office Contact 

Business Type



REFERENCES

TYPE

NAME

CONTACT

CITY

STATE

PHONE

BANK

TRADE

TRADE


BUSINESS RESOLUTION

At a meeting held on the Board of Directors/Partnership/Limited Liability Co./Trust of the above named Practice at the above named address organized and existing under the laws of the State above named, a quorum or all being present and voting it was:
Resolved, that the person signing for the practice is authorized on behalf of the Practice to execute and deliver to IPS any and all documents requested by IPS and that any and all actions taken or documents executed on behalf of Practice are ratified and confirmed and shall continue until written notice of its revocation has been received by IPS.
Resolved, that the Practice, each officer/partner/director/trustee shall indemnify and hold IPS and its assigns harmless from any loss or damage incurred by IPS by acting in reliance upon this resolution.
The undersigned certify that the powers and authority contained in this Resolution have not been rescinded or annulled and are in full force and effect, and that said powers and authority are in conformity and do not contravene or conflict with any provision of those documents organizing and establishing the Practice's business under application law.

IN WITNESS WHEREOF, this Resolution was executed on this date  

Authorized Person      Title 



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