KENTUCKY STATE UNIVERSITY
SCHOOL OF NURSING
400 EAST MAIN STREET FRANKFORT, KENTUCKY 40601
BETTY WHITE HEALTH CENTER
PART D – Complete this part only if there is no contract in place with the agency/site where the Scholarly Project will be implemented.
I am a
Agency Information
Legal name of the agency, clinic, group or entity who owns or has responsibility for the agency/site.
(Note: Legal name may or may not be different)
Office Manager/Administrator
Name:___
Telephone Number with area code: _____
Mailing address of Office Manager/Administrator: ___
(if different from agency mailing address)
City State Zip Code
State Zip Code County
*Person Legally Authorized to Sign Contracts
contracts
Name
Complete Mailing Address ___
Street or P.O. Box
City State Zip Code
State Zip Code County
Telephone Number with area code_____
Fax Number ___ Email
Area code & number
*Note the person legally authorized to sign contracts is usually a different person than the office manager.