Va Form 10-0094c - Medical Education Affiliation Agreement Between Department Of Veterans Affairs (Va) And Institutions Sponsoring Graduate Medical Education Page 4

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PARTICIPATING INSTITUTIONS SIGNATURE PAGES
Requires signature of Designated Institutional Official (DIO) for each
affiliated participating institution listed on page one
Signature of DIO for the Affiliated Participating Institution #1
Signature of DIO for the Affiliated Participating Institution #2
4
4
Date of Signature
Date of Signature
4
4
Typed Name of Individual Signing Above
Typed Name of Individual Signing Above
4
4
Typed Title of Individual Signing Above
Typed Title of Individual Signing Above
4
4
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
4
4
Date of Signature
Date of Signature
4
4
Typed Name of Individual Signing Above
Typed Name of Individual Signing Above
4
4
Typed Title of Individual Signing Above
Typed Title of Individual Signing Above
4
4
Typed Name of Affiliated Participating Institution
Typed Name of Affiliated Participating Institution
VA FORM 10-0094c
PAGE 4 OF 6

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