Fillable Printable Sample Amendment to an Affiliation Agreement

Sample Amendment to an Affiliation Agreement

SAMPLE AMENDMENT TO AN AFFILIATION AGREEMENT

(AMENDMENTS MUST BE SUBMITTED FOR LEGAL

REVIEW)

THIS AMENDMENT, is made and entered into this ________ day of ______________,

between __________________ University of Pennsylvania of the State System of Higher

Education (address), (hereinafter “University”),

and

________________________________________, (Affiliated Entity’s full name, which must be

in its legally recognized form, i.e., corporate registration, full legal name if an individual and

must be the same throughout this Contract. Deviations must be satisfactorily explained, except

that the party may be referred to as “Affiliated Entity” within this document from this point

forward) at (address) acting through its proper officials, hereinafter referred to as “__________”,

Federal I.D. #___________________ (or if an individual, Social Security Number).

WHEREAS, this agreement is for the amendment of the original affiliation agreement

between the _________________ (i.e., “Site, Clinic, Hospital, School, School District”) dated

__________________________; and

WHEREAS, the original affiliation agreement identified above, together with any

previously executed amendments, is attached hereto, and incorporated herein and marked

Attachment A, and all its terms and conditions remain unchanged except as modified in this

amended agreement.

WHEREAS, subsequent to its execution an error (or state need for amendment other

than error) was discovered as to the terms of the affiliation agreement; and

WHEREAS, the parties mutually agree to amend the contract to reflect the correct (or

new/additional information depending on reason for amendment) information as to the term of

the agreement and the number of participants.

NOW THEREFORE, the parties hereto, intending to be legally bound, hereby do agree

to the following amendment:

1. Term of Agreement

. The term of this agreement shall be amended to December

1, 2000 through November 30, 2001.

2. Number of Participants

. The number of participants in this program at any given

time shall not exceed 5 students per semester.

3. Terms of Original Agreement

. All other terms and conditions of the original

agreement not modified in this amendment shall remain in full force and effect

and be considered incorporated herein as part of the amended agreement. Said

original agreement is attached hereto, incorporated herein and marked Attachment

IN WITNESS WHEREOF, this amendment has been executed and delivered as of the

date set forth in the caption above.

University of Pennsylvania Affiliated Entity (Print)

Authorized Signature Authorized Signature

__________________________ ______________________________

Print Name/Title

Approved as to Form and Legality:

______________________________

University Legal Counsel

Date: __________________________