Date: ____________________

TO WHOM IT MAY CONCERN:

I, Antonio Gujil Rivas, a senior citizen, would like to authorize

____________________________ to buy the prescribed medicines on my behalf.
Thank you for your consideration.

ANTONIO GUJIL RIVAS

Senior Citizen

Date: ____________________
TO WHOM IT MAY CONCERN:

I, Antonio Gujil Rivas, a senior citizen, would like to authorize

____________________________ to buy the prescribed medicines on my behalf.
Thank you for your consideration.

ANTONIO GUJIL RIVAS

Senior Citizen

Date: ____________________
TO WHOM IT MAY CONCERN:

I, Antonio Gujil Rivas, a senior citizen, would like to authorize

____________________________ to buy the prescribed medicines on my behalf.
Thank you for your consideration.

ANTONIO GUJIL RIVAS

Senior Citizen

Date: ____________________
TO WHOM IT MAY CONCERN:

I, Antonio Gujil Rivas, a senior citizen, would like to authorize

____________________________ to buy the prescribed medicines on my behalf.
Thank you for your consideration.

ANTONIO GUJIL RIVAS

Senior Citizen

Date: ____________________
TO WHOM IT MAY CONCERN:

I, Antonio Gujil Rivas, a senior citizen, would like to authorize

____________________________ to buy the prescribed medicines on my behalf.
Thank you for your consideration.

ANTONIO GUJIL RIVAS

Senior Citizen