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VII. DECLARATIONS <br /> OTP SPONSOR <br /> I agree on behalf of the program to adhere to all requirements set forth in WAC 388-877, WAC 388-877B, RCW 70.96A, <br /> 42 CFR Part 8.12 and the CSAT Guidelines for the Accreditation of Opioid Treatment Programs. <br /> I also agree to limit the number of individual program participants to 350 as specified in RCW 70.96A.410(1)(e)and <br /> required by WAC 388-877B-0405(2)(d). <br /> Signature of the OTP Sponsor: Date: <br /> Type or Print Name: Title: <br /> Address: Telephone: <br /> t ? <br /> E-mail Address: <br /> OTP MEDICAL DIRECTOR <br /> I assume the responsibility for administering all medical services performed by the OTP. Additionally, I recognize my <br /> responsibility for ensuring that the OTP complies with all applicable Federal, State, and local laws and regulations. <br /> Signature of the OTP Medical Director: Date: <br /> Type or Print Name: Title: <br /> Washington State Licensed Physician Number and Expiration Date: EXPIRES: <br /> Number: <br /> Address: Telephone: <br /> E-mail Address: <br /> OTP Application Addendum—04/18/2017 <br /> Page 4 of 6 <br />