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We certify that the 501(c)(3) status for __________________________________ has not been revoked or modified since creation of the attachment.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:_____________________
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Rev. 03/03