Va Form 10-0094d - Dental Education Affiliation Agreement Between Department Of Veterans Affairs (Va) And A School Of Dentistry As The Sponsoring Institution - 2015 Page 5

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SCHOOL OF DENTISTRY AND AFFILIATED INSTITUTIONS SIGNATURE PAGE
Requires signature of Designated Educational Signer for each affiliated institution listed on page one
Signature of Designated Education Signer for the Affiliated
Signature of Designated Education Signer for the Affiliated
Participating Institution #1
Participating Institution #2
Date of Signature
Date of Signature
Typed Name of Individual Signing Above
Typed Name of Individual Signing Above
Typed Title of Individual Signing Above
Typed Title of Individual Signing Above
Typed Name of Affiliated Participating Institution
Typed Name of Affiliated Participating Institution
Signature of Designated Legal Signer for the Affiliated Participating
Signature of Designated Legal Signer for the Affiliated Participating
Institution #1
Institution #2
Date of Signature
Date of Signature
Typed Name of Individual Signing Above
Typed Name of Individual Signing Above
Typed Title of Individual Signing Above
Typed Title of Individual Signing Above
Typed Name of Affiliated Participating Institution
Typed Name of Affiliated Participating Institution
VA FORM 10-0094d
June 2015
PAGE 5 OF 6

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