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Attachment I <br />Signature Card <br />sue` <br />� {} at <br />CONTRACT & FINANCIAL DOCUMENTS <br />INSTRUCTIONS: Please read and fill in the required information to the right of each field where applicable. <br />Provide the requested printed and written signatures (in Blur Ink) of agency representatives in the designated <br />areas. In the event the affixed signature(s) are no longer valid, a revised form must be submitted prior to <br />processing any contractual documents or submitting "Request for Payments" or any other financial <br />documents. <br />SECTION <br />I. <br />Date: <br />` 1 - _ <br />Legal Applicant Organization /Agency Name: <br />&L'b xt o-,6 e <br />Federal Tax Identification Number: <br />1�D _ CMM I <br />SECTION II. <br />Certification: <br />By affixing my signature below, I certify that person(s) identified are designated having legal authorization to <br />sign on behalf of the organization named in Section I., above, for purposes of executing contractual <br />documents and preparing, approving and executing all financial documents; including "Requests for <br />Payments". I understand the legal implications of any and all misrepresentation of a sole purpose of <br />defrauding the State of North Carolina. <br />NON - GOVERNMENTAL ORGANIZATIONS ONLY <br />Chairman of the Board of Directors (Contract Documents) <br />Financial Representative Signature <br />Print Name: <br />Print Name & Title <br />Signatut•e: <br />Signature: <br />GOVERNMENTAL ENTITIES <br />Appropriate Governmental Official (Secretary, <br />Chief Fiscal Officer Signature <br />Commissioner, etc.) <br />Namee � <br />/,%(I <br />Print Name &Title: <br />A <br />A 1'a - in <br />�� Ogv� , , ,,17744t� <br />YM rh 1� [-C-mn <br />Sid re: <br />Signahi <br />W <br />Signature Card - NGO & Governmental <br />NCaA &CS: Rev 7/11, 2112, 5112, 7112, 8112, 10/12, 5113 <br />Attachment number 2 <br />F -7 Page 250 <br />