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'i � ` y � . <br /> ' ' , , <br /> Metropolitan Life <br /> AND AFFILIATED COMPANIES <br /> l <br /> Metropolitan Life Insurance Company <br /> A Mutual Company Incorporated in New York State <br /> Application ls hereby made to the Company by: <br /> � � �-�j ;�r .:.z=�.;i r�. i,:.. ;�..�._. ��y u:; .� <br /> , <br /> (The Entity Name) <br /> � � �r���,r��� / � �i;��;,_�_.- �,z-,,j i:.�../�"��.�-+ <br /> 4 <br /> (Address) <br /> �„�...(..,..�;� (,/�.;_ ((.,...���'v i..�l�� f �� 4.�.-..-.' , <br /> i;(Address) <br /> Application is hereby made to Metropolitan Life Insurance Company for a group ' <br /> annuity contract providing benefits in accordance with the specifications and data � <br /> furnished by the Entity. �' . I <br /> �'� <br /> It is agreed that the contract, will take effect as of the date the Contract is , <br /> executed by the Company. ', <br /> �f) `-k r_ - I� <br /> .__. .:.,�—.�'�� `��-��,,����x._� �,=�b�h 5 ;'C=(�f, <br /> , <br /> (Entity O�cial Slgnature) (Date) <br /> � <br /> ��1�',.'s,}.Y" 'iJ_��� (�r..�l'y5 � <br /> .(T'�tle�: r �/., + , <br /> �c." � -, � ';�'� �� � ' :';.tl, / <br /> /��,,� ,�'� J;�. B�jP ���L.�..,/''��;�y,�_�S�.U-4��.. - -;�1 . <br /> ,�"I`" �_ � � / � "� �' � <br /> // (Authorized R�presentative Signature) (Date) <br /> ✓ Y <br /> White—Metropolitan Canary—Service Center Pink—Endty Goldenrod—Representadve <br /> DC-2075-B(9/00) <br />