Request For Adeconnect Entity Administrator Account - Arizona Department Of Education
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1Arizona Department of Education
Health & Nutrition Services
Request for ADEConnect Entity Administrator Account
Sponsor Name:
CTD #:
Complete and return this form to the Arizona Department of Education, Health & Nutrition Services.
Upon receipt of this form an ADEConnect, Entity Administrator account will be created for the
organization named above. The Entity Administrator will have authority to setup user accounts that
will have access to the CNPWeb and other Health & Nutrition Services online systems. If the
Designated Official chooses to delegate the responsibility of creating ADEConnect user accounts for
their organization, that individual must be identified in the second box below. All organizations must
have at least one Entity Administrator. All designees must be an Authorized Representative on the
Permanent Food Service Agreement. All email addresses must be to an individual email account,
not an organization wide account.
I am requesting to have an Entity Administrator Account Setup in my name:
Designated Official Name:
Designated Official Email Address:
I am requesting to delegate Entity Administrator Authority to the individual named below:
Authorized Representative:
Authorized Representative Email Address:
By signing below, I am authorizing the Arizona Department of Education, Health & Nutrition Services
to create an ADEConnect Entity Administrator account for the organization named above.
If I
have delegated the Entity Administrator authority to another individual by checking the second box
above, I understand that this person will be given full rights to establish user accounts for other users
and these accounts may have access to submit claims for reimbursement or other sensitive
information. I further acknowledge that the information above is true and correct.
Printed Name of Designated Official
Signature of Designated Official
Date
Printed Name of Authorized Representative
Signature of Authorized Representative Date
Complete and email this form to:
healthandnutrition@azed.gov
This institution is an equal opportunity provider.
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