Va Form 10-0094h - Education Affiliation Agreement Between The Department Of Veterans Affairs (Va) And A Non-Va Health Care Facility Or Agency Page 4

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SIGNATURE PAGE
Signature of Responsible Official for Non-VA Healthcare Facility or
Agency
4
Date of Signature
4
Typed Name of Individual Signing Above
4
Typed Title of Individual Signing Above
Signature of VA Healthcare Facility Discipline Leader
Signature of VA Designated Education Official
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
Signature of Director or Equivalent Responsible Official for VA
Signature of VISN Director or Designee for Department of Veterans
Healthcare Facility
Affairs
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
VA FORM 10-0094h
PAGE 4 OF 4

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