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Red Spouse s/domestic partner s claim cannot be processed without member s signature. * Prior to participating in this benefit, the Management Benefits Fund recommends that you consult with your own physician. VII. HEALTH CLUB FITNESS FACILITY AND MEMBERSHIP INFORMATION: (Please print.) FACILITY NAME: NAME OF FACILITY MANAGER ADDRESS: CITY: TELEPHONE NUMBER: - - STATE: ZIP CODE: FEDERAL TAX I.D.#: MM DD YYYY DATE CURRENT MEMBERSHIP PURCHASED: / / TYPE OF ME.

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