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This Interlocal Agrccment entercd into and Appointment Accepted By: <br />Thc TML Intergovernmental Employce Benefits Pool at Austin, Tcxas <br />By <br />' Date <br />TO I3E COMI'LETED BY EMl'LOYER MEMI3ER: <br />EMPLOYER MEMBER BENEFITS COORDINATOR . <br />Name <br />l'itle <br />Mailing Address <br />Street Address (ifdifierent from abovc) <br />Cih,!State/Zip <br />Plione <br />Fax <br />E-mail <br />Interlocal Ageement (rcv. 06/05/09) - Pagc 5 <br />