Common use of TERMINATION OF AFFILIATION AGREEMENT Clause in Contracts

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY AND AFFILIATED INSTITUTIONS SIGNATURE PAGE 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 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice [insert a date not to exceed ten years in the future and that allows for completion of the last training cycle during that period] and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY OSTEOPATHIC MEDICINE, SPONSORING AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE Requires signature of Designated Institutional Official (DIO) Education Signer for each affiliated participating institution listed on page one Signature of DIO Designated Education Signer for the Affiliated Sponsoring Institution Signature of Designated Education Signer for the Affiliated Participating Institution #1 Signature of DIO for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Sponsoring Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Osteopathic Medicine Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ Officer Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Chief Academic Affiliations Officer, VHA Office of Academic Affiliations, VA Central Office Date of Signature

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice [insert a date that is not to exceed ten years in the future and that allows for completion of the last training cycle during that period] and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. INSTITUTIONS SPONSORING GRADUATE MEDICAL EDUCATION AND THEIR AFFILIATED SCHOOL OF DENTISTRY AND AFFILIATED INSTITUTIONS MEDICINE SIGNATURE PAGE Requires signature of Designated Institutional Official (DIO) for each sponsoring or affiliated participating institution listed on page one Signature of DIO for the Affiliated Participating Sponsoring Institution #1 Signature of DIO for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Sponsoring Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Medicine Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Chief Academic Affiliations Officer, VHA Office of Academic Affiliations, VA Central Office Date of Signature

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE 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 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official DIO for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Affiliated Participating Institution #3 Signature of Responsible VA Official DIO for Educational Program Signature of VA Designated Education Official the Affiliated Participating Institution #4 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #3 Signature of Designated Legal Signer for the Affiliated Participating Institution #4 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of VA Designated Education Official ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Chief Academic Affiliations Officer, VHA Office of Academic Affiliations, VA Central Office ◗ Date of Signature ◗

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY OSTEOPATHIC MEDICINE AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE 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 ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of DIO for the Affiliated Participating Institution #3 Signature of DIO for the Affiliated Participating Institution #4 ⏵ ⏵ Date of Signature Date of Signature ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #3 Signature of Designated Legal Signer for the Affiliated Participating Institution #4 ⏵ ⏵ Date of Signature Date of Signature ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Osteopathic Medicine ⏵ Date of Signature ◗ ⏵ Typed Name of Individual Signing Above ◗ ⏵ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above ⏵ Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Chief Academic Affiliations Officer, VHA Office of Academic Affiliations, VA Central Office ⏵ Date of Signature ⏵

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE 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 (Please sign in ink.) ► Signature of DIO for the Affiliated Participating Institution #2 ◗ ◗ (Please sign in ink.) ► Date of Signature Date of Signature ◗ ◗ ► ► Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ► ► Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ ► ► Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 (Please sign in ink.) ► Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ (Please sign in ink.) ► Date of Signature Date of Signature ◗ ◗ ► ► Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ► ► Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ ► ► Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗(Please sign in ink.) ►

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice [insert a date that is not to exceed ten years in the future and that allows for completion of the last training cycle during that period] and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE Requires signature of Designated Institutional Official (DIO) Educational Signer for each affiliated participating institution listed on page one Signature of DIO Designated Education Signer for the Affiliated Participating Sponsoring Institution #1 Signature of DIO for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Sponsoring Institution Date of Signature Typed Name of Individual Signing Above Typed Title of Individual Signing Above Typed Name of Affiliated Participating Institution Signature of Designated Education Signer for the Affiliated Participating Institution Date of Signature Typed Name of Individual Signing Above Typed Title of Individual Signing Above Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ Officer Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Date of Signature Typed Name of Individual Signing Above Typed Title of Individual Signing Above Date of Signature Typed Name of Individual Signing Above Typed Title of Individual Signing Above Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗Above

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE 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 ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗⏵ ⏵

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE 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 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY OSTEOPATHIC MEDICINE AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE 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 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official DIO for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Affiliated Participating Institution #3 Signature of Responsible VA Official DIO for Educational Program Signature of VA Designated Education Official the Affiliated Participating Institution #4 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #3 Signature of Designated Legal Signer for the Affiliated Participating Institution #4 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Osteopathic Medicine ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of VA Designated Education Official ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Chief Academic Affiliations Officer, VHA Office of Academic Affiliations, VA Central Office ◗ Date of Signature ◗

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY AND AFFILIATED INSTITUTIONS SIGNATURE PAGE 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 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY AND AFFILIATED INSTITUTIONS SIGNATURE PAGE 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 ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ ⏵ Date of Signature ◗ ⏵ Typed Name of Individual Signing Above ◗ ⏵ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗⏵ ⏵

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY MEDICINE AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE 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 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official DIO for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Affiliated Participating Institution #3 Signature of Responsible VA Official DIO for Educational Program Signature of VA Designated Education Official the Affiliated Participating Institution #4 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #3 Signature of Designated Legal Signer for the Affiliated Participating Institution #4 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Medicine ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of VA Designated Education Official ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Chief Academic Affiliations Officer, VHA Office of Academic Affiliations, VA Central Office ◗ Date of Signature ◗

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice [insert a date that is not to exceed ten years in the future and that allows for completion of the last training cycle during that period] and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE Requires signature of Designated Institutional Official (DIO) Educational Signer for each affiliated participating institution listed on page one Signature of DIO Designated Education Signer for the Sponsoring Institution Signature of Designated Education Signer for the Affiliated Participating Institution #1 Signature of DIO for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Sponsoring Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ Officer Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗Above

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE 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 ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official DIO for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Affiliated Participating Institution #3 Signature of Responsible VA Official DIO for Educational Program Signature of VA Designated Education Official ◗ ◗ the Affiliated Participating Institution #4 ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Institution #3 Signature of Designated Legal Signer for the Affiliated Participating Institution #4 ⏵ ⏵ Date of Signature Date of Signature ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ⏵ ⏵ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of VA Designated Education Official ⏵ Date of Signature ⏵ Typed Name of Individual Signing Above ⏵ Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ ⏵ ⏵ Date of Signature Date of Signature ◗ ◗ ⏵ ⏵ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗⏵ ⏵ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Chief Academic Affiliations Officer, VHA Office of Academic Affiliations, VA Central Office ⏵ Date of Signature ⏵

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice [insert a date that is not to exceed ten years in the future and that allows for completion of the last training cycle during that period] and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY AND AFFILIATED INSTITUTIONS SPONSORING GRADUATE MEDICAL EDUCATION SIGNATURE PAGE Requires signature of Designated Institutional Official (DIO) for each sponsoring or affiliated participating institution listed on page one Signature of DIO for the Affiliated Participating Sponsoring Institution #1 Signature of DIO for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Sponsoring Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Sponsoring Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Sponsoring Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ Officer Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Chief Academic Affiliations Officer, VHA Office of Academic Affiliations, VA Central Office Date of Signature

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice [insert a date not to exceed ten years in the future and that allows for completion of the last training cycle during that period] and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. INSTITUTIONS SPONSORING OSTEOPATHIC GRADUATE MEDICAL EDUCATION AND THEIR AFFILIATED OSTEOPATHIC SCHOOL OF DENTISTRY AND AFFILIATED INSTITUTIONS MEDICINE SIGNATURE PAGE Requires signature of Designated Institutional Official (DIO) for each sponsoring or affiliated participating institution listed on page one Signature of DIO Designated Education Signer for the Sponsoring Institution Signature of Designated Education Signer for the Affiliated Participating Institution #1 Signature of DIO for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Sponsoring Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Osteopathic Medicine Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ Officer Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Chief Academic Affiliations Officer, VHA Office of Academic Affiliations, VA Central Office Date of Signature

TERMINATION OF AFFILIATION AGREEMENT. This affiliation agreement is in force until further notice ___________________ [insert a date not to exceed ten years in the future and that allows for completion of the last training cycle during that period] and supersedes any previous or affiliation agreement. It may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience. SCHOOL OF DENTISTRY OSTEOPATHIC MEDICINE, SPONSORING AND AFFILIATED PARTICIPATING INSTITUTIONS SIGNATURE PAGE Requires signature of Designated Institutional Official (DIO) Education Signer for each affiliated participating institution listed on page one Signature of DIO Designated Education Signer for the Affiliated Sponsoring Institution Signature of Designated Education Signer for the Affiliated Participating Institution #1 Signature of DIO for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Designated Legal Signer for the Affiliated Participating Sponsoring Institution #1 Signature of Designated Legal Signer for the Affiliated Participating Institution #2 ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above ◗ ◗ Typed Name of Affiliated Participating Institution Typed Name of Affiliated Participating Institution Signature of Xxxx or Equivalent Responsible Official for the School of Dentistry ◗ Osteopathic Medicine Date of Signature ◗ Typed Name of Individual Signing Above ◗ Typed Title of Individual Signing Above DEPARTMENT OF VETERANS AFFAIRS SIGNATURE PAGE Signature of Responsible VA Official for Educational Program Signature of VA Designated Education Official ◗ ◗ Officer Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗ Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Director or Equivalent Responsible Official for the VA Healthcare Facility Signature of VISN Director or Designee for Department of Veterans Affairs ◗ ◗ Date of Signature Date of Signature ◗ ◗ Typed Name of Individual Signing Above Typed Name of Individual Signing Above ◗ ◗Typed Title of Individual Signing Above Typed Title of Individual Signing Above Signature of Chief Academic Affiliations Officer, VHA Office of Academic Affiliations, VA Central Office Date of Signature Typed Name of Individual Signing Above