Common use of CONTRACTOR California Department of General Services Use Only Clause in Contracts

CONTRACTOR California Department of General Services Use Only. CONTRACTOR’S NAME (if other than an individual, state whether a corporation, partnership, etc.) County of Marin BY (Authorized Signature)  DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING Grant Colfax, MD, Director HHS ADDRESS 00 Xxxxx Xxx Xxxxx Xxxx, Room 2021 San Rafael, CA 94903 STATE OF CALIFORNIA AGENCY NAME Department of Health Care Services BY (Authorized Signature)  DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING X Exempt per: DGS memo dated Xxx Xxxxxxxxx, Chief, Contract Management Unit 07/10/96 and Welfare and Institutions Code 14087.4 ADDRESS 0000 Xxxxxxx Xxxxxx, Xxxxx 00.0000, XX 0000, X.X. Xxx 000000, Xxxxxxxxxx, XX 00000-0000

CONTRACTOR California Department of General Services Use Only. CONTRACTOR’S NAME (if other than an individual, state whether a corporation, partnership, etc.) Mendocino County of Marin Mental Health BY (Authorized Signature)  DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING Grant ColfaxXxx Xxxxxxxxxx, MDMSW, Director HHS ADDRESS 00 Xxxxx Xxx Xxxxx Xxxx, Room 2021 San Rafael000 X. Xxxx Street Ukiah, CA 94903 95482 STATE OF CALIFORNIA AGENCY NAME Department of Health Care Services BY (Authorized Signature)  DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING X Exempt per: DGS memo dated Xxx XxxxxxxxxW&I Code § 14703 Xxxxxx Xxxxx, Chief, Contract Management Unit 07/10/96 and Welfare and Institutions Code 14087.4 ADDRESS Xxxx XXXXXXX 0000 Xxxxxxx Xxxxxx, Xxxxx 00.0000, XX 0000, X.X. Xxx 000000, Xxxxxxxxxx, XX 00000-0000

CONTRACTOR California Department of General Services Use Only. CONTRACTOR’S NAME (if other than an individual, state whether a corporation, partnership, etc.) County of Marin BY (Authorized Signature)  ✍ DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING Grant Colfax, MD, Director HHS ADDRESS 00 Xxxxx Xxx Xxxxx Xxxx, Room 2021 San Rafael, CA 94903 STATE OF CALIFORNIA AGENCY NAME Department of Health Care Services BY (Authorized Signature)  ✍ DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING X Exempt per: DGS memo dated Xxx Xxxxxxxxx, Chief, Contract Management Unit 07/10/96 and Welfare and Institutions Code 14087.4 ADDRESS 0000 Xxxxxxx Xxxxxx, Xxxxx 00.0000, XX 0000, X.X. Xxx 000000, Xxxxxxxxxx, XX 00000-0000

CONTRACTOR California Department of General Services Use Only. CONTRACTOR’S NAME (if other than an individual, state whether a corporation, partnership, etc.) Mendocino County of Marin Mental Health BY (Authorized Signature)  ✍ DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING Grant ColfaxXxx Xxxxxxxxxx, MDMSW, Director HHS ADDRESS 00 Xxxxx Xxx Xxxxx Xxxx, Room 2021 San Rafael000 X. Xxxx Street Ukiah, CA 94903 95482 STATE OF CALIFORNIA AGENCY NAME Department of Health Care Services BY (Authorized Signature)  ✍ DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING X Exempt per: DGS memo dated Xxx XxxxxxxxxW&I Code § 14703 Xxxxxx Xxxxx, Chief, Contract Management Unit 07/10/96 and Welfare and Institutions Code 14087.4 ADDRESS 0000 Xxxxxxx Xxxxxx, Xxxxx 00.0000, XX 00001403, X.X. Xxx 000000P.O. Box 997413, XxxxxxxxxxSacramento, XX 00000CA 95899-00007413

CONTRACTOR California Department of General Services Use Only. CONTRACTOR’S NAME (if other than an individual, state whether a corporation, partnership, etc.) County of Marin BY (Authorized Signature)  ✍ DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING Grant Colfax, MD, Director HHS ADDRESS 00 Xxxxx Xxx Xxxxx Xxxx, Room 2021 San Rafael, CA 94903 STATE OF CALIFORNIA AGENCY NAME Department of Health Care Services BY (Authorized Signature)  ✍ DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING X Exempt per: DGS memo dated Xxx Xxxxxxxxx, Chief, Contract Management Unit 07/10/96 and Welfare and Institutions Code 14087.4 ADDRESS 0000 Xxxxxxx Xxxxxx, Xxxxx 00.0000, XX 0000MS 1400, X.X. Xxx 000000P.O. Box 997413, XxxxxxxxxxSacramento, XX 00000CA 95899-00007413