Form Spi 1576 Sample Letter To Board Members, Managers, And Supervisors In Organizations Participating - Cacfp Page 4

• The manager or president of a corporation or a Limited Liability Corporation; or

• The executive director, or comparable director of operations, of the CACFP in a private

nonprofit, proprietary, or public institution applying to participate in CACFP:

• Any other supervisory or management position within the organization.

My date of birth is:

My business mailing address is:

My full name is:

Legal signature: ____________________________________

NOTE: Any organization or individual that provides false information on this form will be

subject to applicable civil or criminal penalties.

OSPI/Child Nutrition Services

FORM SPI 1576 (Rev. 8/05)

Page 4

Attachment 15 to Bulletin No. 43-2012 CNS

September 25, 2012

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