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     I am of legal (majority age).  I enter into this relationship of my own free will.  I reserve the right to revoke Mr. Meyer's authority as my cognitive interpreter at any time.

 

     Unless I choose to terminate this agreement at an earlier date, it shall remain in effect until the termination of my relationship with Mr. Meyer, the disposition of my case or the satisfactory conclusion of business with the persons or agencies referred to above.

 

     I have read or have had another person read this agreement to me, and I understand it.

 

Persons or Agencies

 

1.  Agency or Institution:_______________________________________________________

 

     Person or persons:___________________________________________________________

 

     Title or agency relationship:____________________________________________________

 

 

 

2.  Agency or Institution:_______________________________________________________

 

     Person or persons:___________________________________________________________

 

     Title or agency relationship:____________________________________________________

 

 

3.  Agency or Institution:_______________________________________________________

 

     Person or persons:___________________________________________________________

 

     Title or agency relationship:____________________________________________________

 

 

4.  Agency or Institution:_______________________________________________________

 

     Person or persons:___________________________________________________________

 

     Title or agency relationship:____________________________________________________

 

 

___________________________________     ________________________________________

                        (Witness)                                                                                     (Witness)

 

 

X__________________________________     _______________________________________

                        (Individual)                                                                     Roger N. Meyer

 

 

Date:_________________________________

 

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