ARIZONA DEPARTMENT OF EMERGENCY AND MILITARY AFFAIRS
DESIGNATION OF APPLICANT’S AGENT FORM
The intent of this DESIGNATION is to appoint an APPLICANT’S AGENT for the following:
Applicant:
CERTIFICATION
I, , duly appointed and of
(Authorizing Official’s Name) (Title)
, do hereby certify that the information below is true and correct,
(Applicant)
based on a resolution passed and approved (attached) by the
(Governing Body)
of on the day of , .
(Applicant) (day) (month) (year)
has been designated as the Applicant's Agent
(Name of Designated Applicant's Agent)
to act on behalf of .
(Applicant)
(Authorizing Official’s Signature) (Title) (Date)
Designated Applicant’s Agent
Cell
Name
Title/Official Position
Full Mailing Address
Email Address
Daytime Telephone Number
(Please
include area code and extension if not a direct number)
Select program(s)
Select duration
Public Assistance
Until further notice
Received By: ______________________
March 2020
(Initials & Date)
This document MUST be accompanied by a copy of the Resolution or Meeting
Minutes by your governing board which designated the Applicant's Agent.
HMA Mitigation Program
Only Event _________
From _______ to ________
SEC Mitigation
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signature
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