PLEASE NOTE: Proposals cannot be recommended for funding to the Milwaukee County Board until the Authorization to File is completed and received by DHHS Contract Administration. This is to certify that at the (Date) meeting of the Board of Directors of _____________ (Agency Name), the following resolution was introduced by (Board Member's Name), and seconded by Member's Name), and unanimously approved by the Board: BE IT RESOLVED, that the of Directors of ____________ (Agency Name) hereby authorizes the filing of a proposal for the Year 2014 Milwaukee County Department of Health and Human Services (DHHS) funding. In connection therewith, ___________ (Name and and _______ (Optional Name(s) and Title) is (are) authorized to negotiate with DHHS staff. In accordance with the Bylaws (Article , Section ) of __________________ (Agency Name), ___________ (Name and and (Optional Name(s) and Title) is (are) authorized to sign the Year 2014 Purchase of Service Contract(s). Name: _____________________ (Signature of the Secretary of the Board of Directors) Date: ________________ Printed Name: _________________________________ YEAR 2014 AGENCY DESCRIPTION AND ASSURANCES ITEM # 4 Please check all the statements below that describe your business entity: Corporation Venture Service Corporation (SC) For-Profit Limited Liability Company (LLC) Sole Proprietorship Non-Profit Single Member LLC Individual Credentialed Provider
PLEASE NOTE: Proposals cannot be recommended for funding to the Milwaukee County Board until the Authorization to File is completed and received by DHHS Contract Administration. This is to certify that at the (Date) meeting of the Board of Directors of _____________ (Agency Name), the following resolution was introduced by (Board Member's Name), and seconded by Member's Name), and unanimously approved by the Board: BE IT RESOLVED, that the of Directors of ____________ (Agency Name) hereby authorizes the filing of a proposal for the Year 2014 Milwaukee County Department of Health and Human Services (DHHS) funding. In connection therewith, ___________ (Name and and _______ (Optional Name(s) and Title) is (are) authorized to negotiate with DHHS staff. In accordance with the Bylaws (Article , Section ) of __________________ (Agency Name), ___________ (Name and and (Optional Name(s) and Title) is (are) authorized to sign the Year 2014 Purchase of Service Contract(s). Name: _____________________ (Signature of the Secretary of the Board of Directors) Date: ________________ Printed Name: _________________________________ YEAR 2014 AGENCY DESCRIPTION AND ASSURANCES ITEM # 4 Please check all the statements below that describe your business entity: Corporation Venture Service Corporation (SC) For-Profit Limited Liability Company (LLC) Sole Proprietorship Non-Profit Single Member LLC Individual Credentialed Provider