This form must be submitted by January 1 and July 1 each year.
Name of Plan: Address: Telephone: Email address: Authorized Signature: Title: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form. The official records of the above Prepaid Service Plan indicate that the following representatives are authorized in Kansas as of (Date) REPRESENTATIVES NAMES City, State, Zip
