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<br />EXECUTED IN DUPLICATE ORIGINALS ON THE DATES SHOWN. <br /> <br />CITY OF PARIS <br />Authorized Contracting Entity (type above if different <br />from PERFORMING AGENCY) for and in behalf of: <br /> <br />PERFORMING AGENCY NAME: <br /> <br />PARIS-LAMAR COUNTY HEALTH <br />DEPARTMENT <br /> <br />By: <br /> <br />(Signature of person authorized to sign contracts) <br /> <br />(Name and Title) <br /> <br />Date: <br /> <br /> <br />RECEIVING AGENCY NAME: <br /> <br />DEPARTMENT OF STATE HEALTH <br />SERVICES <br /> <br />By: <br /> <br />~ <br /> <br />(Signature of person authorized to sign contracts) <br /> <br />Bob Burnette, Director <br />Procurement and Contracting Services Division <br />(Name and Title) <br /> <br />Date: <br /> <br />DSHS Document No: 7560022067 A2005 <br /> <br />Cover Page 3 <br />