Literature & Medicine Application Contract Form printable pdf download

Literature & Medicine Application Contract Form

Literature & Medicine

APPLICATION CONTRACT FORM

Literature & Medicine: Humanities at the Heart of Health Care™

Carefully read the

Request

for Application, complete and submit this form by downloading the document and having both

parties sign and complete the form below. Scan completed form and upload it with the

application form. Your application cannot be considered if this form is missing or incomplete.

By signing this form, I certify that the institution agrees to follow the requirements and

responsibilities outlined in the request for application document if it receives funding, including

working closely with Mass Humanities, and assuming financial responsibility as outlined.

statements contained herein are true, complete and accurate to the best of my knowledge.

Host Liaison (I have read and agree to the Liaison responsibilities):

Print Name____________________________________ Professional Title_______________________

Signature_____________________________________

Date___________________

Authorizing Official (I have read and agree to abide by the institution’s responsibilities):

Print Name____________________________________ Professional Title_______________________

Signature_____________________________________

Date___________________

Literature & Medicine Application Contract Form