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IN WITNESS WHEREOf, th® Employer has caused this Adoption <br />Agreement to be eyecuted by its duly authorized officer on this <br />_ _ _ _ day of _ , 19 _ _, in the City of _ _ _ _ _ _ <br />and the State of <br />Authorized Signature: <br />Title: <br />STATE OF . <br />COUNTY OF <br />The foregoing instrument was acknovldeged before me this <br />. day of_ _ _ _ _ _ _ _ _; 19 _ _, by _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br />(office held) <br />(name of officer) <br />__ _ _ _ _ _on behalf <br />(name of company) <br />(name of company) <br />Notary Public <br />My Commission Expires: