Health And Nutrition Services Entity Data Form

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Health and Nutrition Services Entity Data Form

v4.1

Fax To:

Select Applicable Program

NSLP

SFSP

CACFP

(602) 542-1531

Sponsor Information

I am requesting the creation of a brand new Sponsor

I am requesting a change to the Site(s)

I am requesting a change to the Sponsor name

Sponsor Name

Sponsor CTDS#

Physical Address

City

State

Zip_________

Mailing Address________________________________________________________________________________________

City______________________________________________________ State

Zip___________

Site Information

I am requesting a change to the Site name

I am requesting the creation of a brand new site

I am requesting that the Site be deleted

Non-Associated Site

Associated Site

if brand new site:

Site Name________________________________________________________________________________________

Site CTDS#_______________________________________________________________________________________

Physical Address________________________________________________________________________________________

City_____________________________________________________ State

Zip_____________

Authorized Signer Information

(The Governing Board Member that is listed on the Certification Page of the ADE Food Program Permanent Service

Agreement Contract; or a Designated Official/Authorized Representative that is listed on the last page of the ADE Food Program Permanent Service Agreement Contract.)

Name

Title

Phone

E-Mail

Authorized Signature

Date

ADE STAFF USE ONLY

For PY: ___________

Program Approval: ___________________________________________________________ Date: ______________________

FOR NEW SPONSORS ONLY

Please Check One Below:

For-Profit Child Care Centers