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11-03-2005 13:39 WT5EPL.RCE 7145423653 PRGE6 <br />XII Agreennew <br />1 have, read the. afhrcnicntioncd Agency Ageocmcnt and waiver for use of technology olUe LA/UC HMIS, <br />Equipment and Scrviccs (if'vj7phvubIc), and thoroughly understand that this technology is for LA/UC. <br />HMIS purposes only. <br />This Agreement is executed h®tween WISE Place Huta) for Wemeu and UC' lwio mhi, and upon <br />execution thu Agency will be given access to the ) IMIS. This agrccnwnt will be signed by the Rxecutive <br />Director at the Patticipating Agency. <br />Lxec,tive Director's Name (Print) <br />l' hive I)irector's Signature <br />Agency Name <br />I v JA4'J o6 <br />Date of Sigruirure <br />C nti uunt Representative's Name ('Print) <br />Continuum Representative's Signature; <br />ContinuumNa <br />j J <br />Dae of SiVta ure <br />HMSS Agericy Agra:eMe,n/ Page 5 (7j,5 Rovisely 10/03/05 <br />