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Contract ~~t L86076-(08 <br />Noi~kh Carolina t3aptist I lospital <br />II. The site(s) for the performance of work done in connection with the specific agreement are listed below: <br />(Street address) <br />(City, county, state, zip code) <br />(Street address) <br />(City, county, state, zip code) <br />Contractor will inform the County of any additional sites for performance of work under this agreement. <br />False certification or violation of the certification shall be grounds for suspension of payment, suspension or <br />termination of grants, or government-wide Federal suspension or debarment (Section 4 CFR Part 85, Section <br />85.615 and 86.620). <br />S' atur Title <br />/VG ~ ,~- <br />Agency/Organization <br /> <br />7 i. i, <br />Date <br />(Certification signature should be same as Contract signature.) <br />Contract-General (06/04) Page 12 of 19 <br />