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This [nterloca! Agrcement entered into and Appointment Acccpted By: <br />Thc TML Intergovemmental Employce Benefits Poul at Austin, "fcxas <br />By <br />Date <br />TO I3E COMI'LETED 13Y EMPLOYER MEMl3ER: <br />EMPLOYER MEMBER BFNEFITS COORDINA'TOR <br />Name <br />l'itlc <br />Mailing Address <br />Street Address (ifdifferent from abovc) <br />Cih,lState/Zip <br />Phone <br />Fax <br />E-mail <br />Intcrlocal Agreemant (rev. 06/05/09) - Yage 5 <br />