Board Of Directors Resolution Form - Section C

Board Of Directors Resolution Form - Section C - 2

Board of Directors Resolution Form

Section C - 2

Required for non-individual applicants only and must be an original, notarized form.

For non-individual applicants, this form must only be filled out once and submitted with the

application for the group/payee number.

State of ___________________________

County of __________________________

On the

day of

at a meeting of the Board

of Directors of

, held in the City of

County, with 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 does hereby authorize

___________________________________________________________________________________

and his/her successors in office to negotiate, on terms and conditions that he/she may deem advisable, a

contract or contracts with the Mississippi Medicaid agency and to execute said contract or contracts, and

further we do hereby give him/her the power and authority to do all things necessary to implement,

maintain, amend, or renew said contract.

The above resolution was passed by a majority of those present and voting in accordance with the

bylaws.

I certify that the above 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

,_______________

___________________________________

Signature of Board Member

Subscribed and sworn before me,

, a Notary Public for the

County of

, on the

day of ____________________

Notary Stamp/Seal

Notary County Of

State Of

Section C – 2, Page 1 of 1

Board Of Directors Resolution Form - Section C - 2