Statement of Agreement, Authorization, and Certification

STATEMENT OF AGREEMENT, AUTHORIZATION AND CERTIFICATION

 

Agency Name:                  __________________________________________________

Address:                            __________________________________________________

Telephone:                         __________________________________________________

Proposal Request:              __________________________________________________

Designated Spokesperson:__________________________________________________

Alternate Spokesperson:   __________________________________________________

Statement of Agreement:
We agree to furnish a report on expenses related to products and services funded by the grant.   We accept the terms and conditions set out in Exhibit A of the VNA Foundation, Inc.  Grants Policies and Procedures Statement, Attached hereto. 

Authorization:
Our signatures acknowledge that the information contained in this funding proposal may be shared with other funders.  In addition, this certifies that this request is consistent with our organization’s Mission/Articles of incorporation and Bylaws and has been approved by a majority of the Board of Directors on (date):
___________________ .

Statement of Certification:
We certify that the 501(c)(3) status for __________________________________ has not been revoked or modified since creation of the attachment.

___________________________________                                                          _______________________________________
    Typed named of Agency Administrator                                                                    Typed Name of Board Officer

___________________________________                                                         ________________________________________
                  Signature                                                                                                                    Signature

Date:___________________ 
Date:_____________________

                                     

 

Rev. 03/03