Note 1 - Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board This is the address where the signed contract and all relevant legal Resolution). correspondence will be mailed. This should be the individual who signs the SLD (page 23). This may not be the same individual as noted in the Annex A summary sheet. In the event of emergency notification, please include e-mail and fax number. Contract Signatory Title Mailing Address Telephone Number - - Fax Number - - E-Mail Address
Note 1 - Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board Resolution). This is the address where the signed contract and all relevant legal correspondence will be mailed. This should be the individual who signs the SLD (page 23). This may not be the same individual as noted in the Annex A summary sheet. In the event of emergency notification, please include e-mail and fax number. Contract Signatory Title Mailing Address Telephone Number - - Fax Number - - E-Mail Address
service_health_rshp_annexa.docx