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.