Signature Page Form


 Between SCDMH and the Community Mental Health Centers
For Supplemental Funding to Hire Peer Support Specialists

To accept this Memorandum of Agreement, sign and date this form and return to the SCDMH Office of Consumer Affairs/SCDMH Administration Building, by September 30, 2003.

TO: Office of Consumer Affairs, Director

I have read the Introduction to this Memorandum of Agreement and I agree to its Terms of Agreement (found on pages 8-9).

I plan to hire (circle one) one or two consumer candidates for the position of Peer Support Specialist and will expect to receive (circle one) $5,000 or $10,000 in supplemental funding from SCDMH.

My signature below attests to my intent to fulfill the obligations of this Memorandum of Agreement.

Signature:         (sign) __________________________

Name:              (print) __________________________
Title:                 _______________________________
Center Name:   _______________________________

Today’s Date:   ________________

Return by September 30, 2003

Interagency Return Mailing Address:
SCDMH Administration Building

Or by regular mail:
Office of Consumer Affairs
SCDMH Administration Building
P.O. Box 485
Columbia, SC  29202

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