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Page 5 of 8 <br /> <br />If you have a disability and need this document in another format, please call 1 -800-525-0127 (711-TTY relay). <br />DOH 348-576 November 2017 <br /> <br /> <br />Provider/Plan: <br /> <br />Contact Person and Title: <br /> <br />Organization: <br /> <br />Mailing Address: <br /> <br />City/State/Zip: <br /> <br />Phone: Fax: E-mail: <br /> <br />DOH: <br /> <br /> <br />Mail to: Washington State Department of Health <br /> Office of Immunization and Child Profile <br /> PO Box 47843 <br /> Olympia, WA 98504-7905 <br />Phone: 360-236-3595 or 1-866-397-0337 <br /> <br /> <br /> <br />AGREED on this _______ day of _________________, 20______. <br /> <br />By execution of this agreement, the parties so signing acknowledge they have full power and authority to enter <br />into and perform this agreement on behalf of the signatory as well as the business entity referenced within the <br />body of the agreement. <br /> <br />Agency Signatory: Washington State Department of Health: <br /> <br />___________________________________ ___________________________________ <br />Signature Contracts Office Authorized Signature <br /> <br />___________________________________ ___________________________________ <br />Name, Title Please Print Name, Title Please Print <br /> <br /> <br />Provider Signatory: (The Agency’s licensed healthcare provider, school nurse, child care health consultant, <br />or other authorized healthcare provider, licensed in Washington State, and responsible for the operation and <br />management of Agency’s healthcare services.) <br /> <br /> <br />___________________________________ <br />Signature <br /> <br />___________________________________ <br />Name, Title Please Print <br />