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<br />68/22/266& 69:5& <br /> <br />365995189& <br /> <br />MDCPS <br /> <br />PAGE 64/65 <br /> <br />Affiliating Agreement <br />Page ---L- of ~ <br /> <br />o <br /> <br />Organization shall furnish a fully completed certificate of insurance signed by an authorized representative <br />of the insurance company providing such coverage. If the Organization is a state agency or subdivision lIS <br />defined by section 768,28, Florida Statutes, the Organization shan furnish, upon request, written <br />verification oftlle liability protection in accordance with section 768.28, Florida Statutes. <br /> <br />'\\, <br />" <br />, <br /> <br /> <br />1/;~ fJ(Y <br /> <br /> <br />t Date I <br /> <br />~=~~~ -=-~ <br />~n "- <br />TIlE SCHq?~ B~fRD ~~IAMJ.nADE COUNTY, FLORID: <br />" d, , l\-':f~;:,,:j. Carolyn Sp3r <br />Mvlj ~/ Chief of Stall <br />, , 'rinten ent 01 chao s or esignee) <br /> <br /> <br />Date <br /> <br />'cot r <br />II <br /> <br />~11, /\ ~ <br />L '<<isk Managemen <br /> <br />...-;---.' <br /> <br />~/;~~ <br />\ J ( <br />In!.Q DC <br />!O(~(2h <br /> <br />Date <br /> <br />APPROVED AS TO FORM: <br /> <br /> <br />---< ';,,1~l-kDfl <br /> <br />\ \ / lIifJ,p <br />, Date <br /> <br />FM-6103 Rev, (02.Q6) <br /> <br />I <br />I <br />