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Of course, her recovery takes priority. Of course, her recovery takes priority. Applied Behavior Analysis Solutions
P.O. Box 832
Pinellas Park, FL 33780
Phone: (727) 492-5369 Fax: (727) 545-8429
Consent to Use Electronic Signature
I, _____________________________________, have provided ABA Solutions, Inc. with a copy of my electronic signature. I give permission for ABA Solutions, Inc. to use my electronic signature as it pertains to all documents produced by me as a contractor for ABA Solutions, Inc and as it pertains to behavior analytic/behavior assistant services that I provide as a contractor for this agency.
I agree to have my signature used for the purposes of signing documents that will remain in digital storage, media files, and/or to be printed for hard copy files. ABA Solutions, Inc. is permitted to share documents which contain my electronic signature with relevant supports and providers permitted to receive information pertaining to specific clients (i.e. waiver support coordinators).
I understand that consent to use my electronic signature will remain valid without expiration unless I (1) withdraw my consent in writing, or (2) am no longer contracted by ABA Solutions, Inc. to provide this service (finalized by signing a termination agreement). I may withdraw consent at any time without penalty; withdrawal must be in writing and submitted to the address listed above.
Date Position of Contractor at time of signature
Name of Contractor Signature of Contractor
Name/Position of Witness Signature of Witness
** Witness should be agency administrator, officers, or other agency administration personnel