Health And Nutrition Services Entity Data Form - Arizona Department Of Education
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Health and Nutrition Services Entity Data Form
v4.1
Fax To:
Fax To:
Select Applicable Program
NSLP
SFSP
CACFP
(602) 542-1531
(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
AZ
City
State
Zip_________
Mailing Address________________________________________________________________________________________
AZ
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________________________________________________________________________________________
AZ
City_____________________________________________________ State
Zip_____________
Authorized Signer Information
(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
Non-Profit Child Care Center
Private Non-Profit Organization
Adult Day Care Center
Residential Child Care Institution (Non-Gov’t)
Day Care Home Sponsor
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Parent category: Legal