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CALIFORNIA DENTAL SERVICE <br /> (A Not-for-profit Corporation) <br /> <br /> P.O. Box 7736, San Francisco, California 94120 <br /> <br /> Group f~ 2].05 <br /> <br />APPLICATION FOR DENTAL CARE SERVICE CONTRACT <br /> <br /> CITY OF REDWOOD CITY <br /> <br />herein sometimes called Applicant, hereby applies for a DENTAL CARE SERVICE CONTRACT with CALIFORNIA DENTAL <br />SERVICE, herein called 'CDS", on the following terms: <br /> <br />I. Applicant agrees to pa,/to COS, monthly in advance, the Dues specified on behalf of each Employee eligible under the <br />Contract. <br /> <br /> I1. Upon acceptance of this Application by COS and payment by the Applicant of the Initial Dues, the Effective Date of the <br /> <br />Contract shall be 12:01 a,m., on the first day of. Iv[stol/ ,197 8 , and the Contract shall continue <br />until terminated in accordance with the provisions therein. <br /> <br />Ill. Applicant designates a Group Representative, named below, who shall be responsible for providing to each Eligible Em- <br />ployee a copy of the Evidence of Coverage furnished to Applicant by COS and for disseminating all notices delivered by CDS to <br />Applicant affecting the rights of such employee under this Contract within a reasonable time but in no event later than thirty <br />(30) days after receipt. <br /> <br /> GROUP REPRESENTATIVE Date March 15, 1978 <br /> (Address) (Title) <br /> <br /> (Authorized Signature) <br /> <br /> (Titra) <br /> <br /> -1- <br /> 11-77 AD/RET <br /> <br /> <br />