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Clearinghouse Trading Partner Agreement - DHHR - State of West ...

Clearinghouse Trading Partner Agreement - DHHR - State of West ...

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SIGNATURESThe Parties will be bound by all the terms, provisions and conditions <strong>of</strong> this <strong>Agreement</strong> upon execution <strong>of</strong> the<strong>Agreement</strong> by each Party’s authorized representative.Agreed To:___________________________________Company__________________________________Name___________________________________Title___________________________________Address___________________________________Address___________________________________City___________________________________<strong>State</strong>, ZIP___________________________________Contact___________________________________Title___________________________________Telephone___________________________________Fax___________________________________Tax Identification Number___________________________________Email___________________________________Signature___________________________________DateAgreed To:Unisys Corporation___________________________________Name___________________________________Title___________________________________Address___________________________________Address___________________________________City___________________________________<strong>State</strong>, ZIP___________________________________Contact___________________________________Title___________________________________Telephone___________________________________Fax___________________________________Tax Identification Number___________________________________Email___________________________________Signature___________________________________DateUnisys <strong>Clearinghouse</strong> <strong>Trading</strong> <strong>Partner</strong> <strong>Agreement</strong> rev. 3.8.2004 Page 6 <strong>of</strong> 6

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