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r ~• <br />Department of State Health Services <br />~' <br />b <br />Signature of Author ed fficial <br />Date: <br />~- ~1~~~ <br />Evelyn Delgado <br />Assistant Commissioner for Family and Community Health <br />Services <br />1100 WEST 49TH STREET <br />AUSTIN, TEXAS 78756 <br />512.458.7321 <br />Evelyn.Delgado@dshs. state.tx.us <br />Contractor <br />Signature of Auth rized Official <br />Date: ~I u <br />Name: ~ ~CK M~ VIC~gC~I <br />Title: ~_ ~ Q,r, ~~ f <br />r <br />Address: ~C Jd E ' 1'f a~ ~{",ri c <br />~+r~ ~ a r X05 ~~ X 7 ~ rQ r~ (c <br />Phone: 5 ~~" c.~ l 3_ O ~~}~ <br />Email: f Cron C~n.Q~.~(o, C.1 . S~i.rt' rnc~Yeos.-~X . u S <br />Page - 2 of 2 <br />