IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the dates below their signatures. CONTRACT NUMBER: C029100____________________ CONTRACTOR: STATE AGENCY: New York State Department of Health Mary Doe, MD By: By: Mary Doe, MD Karen Westervelt Printed Name Printed Name Title: Title: Physician Deputy Commissioner Date: Date: STATE AGENCY CLARIFICATION: the acceptance of this contract, I “In addition to also certify that original copies of this signature page will be attached to all other exact copies of this contract.” STATE OF NEW YORK ) ) SS: County of______________) On the ______ day of _______________, _______, before me personally appeared __________________________, to me known, who being by me duly sworn, did depose and say that he/she resides at _____________________, that he/she is the ________________________ of the _________________________________, the corporation described herein which executed the foregoing instrument; and that he/she signed his/her name thereto by order of the board of directors of said corporation. ___________________________________________________ (Notary) ATTORNEY STATE SIGNATURE GENERAL’S SIGNATURE COMPTROLLER’S Title: Title: Date: Date:
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the dates below their signatures. CONTRACTOR: Mary Doe, MD By: Mary Doe, MD Printed Name Title: Physician Date: CONTRACT NUMBER: C029100____________________ STATE AGENCY: New York State Department of Health By: Karen Westervelt Printed Name Title: Deputy Commissioner Date: STATE AGENCY CLARIFICATION: “In addition to the acceptance of this contract, I also certify that original copies of this signature page will be attached to all other exact copies of this contract.” STATE OF NEW YORK ) ) SS: County of______________) On the ______ day of _______________, _______, before me personally appeared __________________________, to me known, who being by me duly sworn, did depose and say that he/she resides at _____________________, that he/she is the ________________________ of the _________________________________, the corporation described herein which executed the foregoing instrument; and that he/she signed his/her name thereto by order of the board of directors of said corporation. ___________________________________________________ (Notary) ATTORNEY GENERAL’S SIGNATURE Title: Date: STATE COMPTROLLER’S SIGNATURE Title: Date:
grant_boilerplate_multi_dany_lrp_cycle_iii.docx