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Provider/Plan: <br />Contact Person and Title: <br />DOH: <br />Mail to: <br />Phone: <br />Washington State Department of Health <br />Office of Immunization and Child Profile <br />PO Box 47843 <br />Olympia, WA 98504-7905 <br />360-236-3595 or 1-866-397-0337 <br />AGREED on this ~day of __ J_~_ll\.tJ ____ . 2ollli_. <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 />Page 5 of 8 <br />If you have a disability and need this document in another format, please call l-800-525-0127 (711-TTY relay). <br />DOH 348-576 November 2017