Bhsf Form Ac-2a Standard Board Resolution Form

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BHSF Form AC-2a
Revised January 2011
STANDARD BOARD RESOLUTION FORM
Sample Form: You may use this form or your own Board Resolution Form.
(This document is necessary for the Medicaid Application Center Program when it is required by your
Board of Directors. If it is not required, please indicate this on the Contractual Agreement)
STATE OF LOUISIANA, PARISH OF:_____________________________________________
on the__________day of_________________, ____________at a meeting of the Board of Directors of
Month
Year
held in the City of:___________________________________________________________________
a quorum of the Directors present, the following business was conducted:
It was duly moved and seconded that the following resolution be adopted:
BE IT RESOLVED that the Board of Directors of the above corporation do hereby authorize
_________________________________________________________________(Name and Title)
and his/her successors in the office to negotiate, on terms and conditions that he/she may deem
advisable, a contract or contracts with the Louisiana Department of Health and Hospitals, and to
execute said documents on behalf of the corporation, and further we do hereby give him/her the
power and authority to do all things necessary to implement, maintain, amend, or renew said
documents.
The above resolution was passed by a majority of those present and voting in accordance with the
by-laws and articles of incorporation.
I certify that the above and foregoing constitutes a true and correct copy of a part of the minutes of a
meeting of the Board of Directors of:
____________________________________________________
____________________________________________________
Held on the ______day of____________________, __________.
Month
Year
Secretary____________________________________________.
Subscribed and sworn before me, __________________________________________a Notary Public
for the Parish of______________________ on the_____day of_______________Month________Year

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