"Add/Change/Delete Health and Nutrition Services Entity Data Form" - Arizona

Add/Change/Delete Health and Nutrition Services Entity Data Form is a legal document that was released by the Arizona Department of Education - a government authority operating within Arizona.

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Add/Change/Delete
Health and Nutrition Services Entity Data Form v4.3
Select Applicable Program:
NSLP
SFSP
CACFP
CACFP/At Risk
Other______________
Sponsor Entity 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 □
Same as Physical Address________________________________________________________________
City: ______________________________________
State: _______
Zip: _______
Telephone: _____________________ Fax:_______________ Website:___________________________________
Authorized Signer Information
(Designated Official/Authorized Representative that is listed on the last page of the ADE Food Program Permanent Service Agreement Contract)
Name: ____________________________________ Phone:__________________E-mail:______________________
Authorized Signature:________________________________________________Date:________________________
ADE Staff Use Only
Program Year (if changing mid-year, date must be the first of the month): _________________________________
Program approval signature: _________________________________________ Date: _______________________
For New Sponsor/Site Entities:
Child Care Center
Adult Care Center
Non-Public Organization
Private School
Faith Based
Residential Treatment Center
Tribal Group
Additional Entity Details:
Public vs Private (select one):
Profit Status (select one)
Public
Private
For Profit
Not for Profit
Notes:
Note to Program Staff: Please ensure proper documentation is submitted to Entity Manager or the entity cannot be created.
Add/Change/Delete
Health and Nutrition Services Entity Data Form v4.3
Select Applicable Program:
NSLP
SFSP
CACFP
CACFP/At Risk
Other______________
Sponsor Entity 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 □
Same as Physical Address________________________________________________________________
City: ______________________________________
State: _______
Zip: _______
Telephone: _____________________ Fax:_______________ Website:___________________________________
Authorized Signer Information
(Designated Official/Authorized Representative that is listed on the last page of the ADE Food Program Permanent Service Agreement Contract)
Name: ____________________________________ Phone:__________________E-mail:______________________
Authorized Signature:________________________________________________Date:________________________
ADE Staff Use Only
Program Year (if changing mid-year, date must be the first of the month): _________________________________
Program approval signature: _________________________________________ Date: _______________________
For New Sponsor/Site Entities:
Child Care Center
Adult Care Center
Non-Public Organization
Private School
Faith Based
Residential Treatment Center
Tribal Group
Additional Entity Details:
Public vs Private (select one):
Profit Status (select one)
Public
Private
For Profit
Not for Profit
Notes:
Note to Program Staff: Please ensure proper documentation is submitted to Entity Manager or the entity cannot be created.
Multi-Site Form
(To be included when requesting action for more than one site)
Sponsor Name: ________________________________________________________________
Sponsor CTDS: ________________________________________________________________
Site Entity Information
If entity is a public school (District or Charter) only fill out the fields marked with **
I am requesting a change to the site name
I am requesting the creation of a brand-new site
Old Name:____________________________________
Non-Associate Site
Associated Site
This site is no longer participating in the program
(This selection may remove site from CNPWeb)
**Site Name: _____________________________________________________________________
**Site CTDS:_____________________________________________________________________
Physical Address: ________________________________________________________________
City: _____________________________________________
State_____
Zip_______
_____________________________________________________
Mailing Address:
Same as Physical Address
City: _____________________________________________
State_____
Zip_______
Telephone: ________________ Fax:_______________ Website:__________________________
Childcare facilities only, please select one:
Alternate approval
Department of
Department of Economic
Department of Health
Tribal License
Defense License
Security License
Services License
*Click here for additional Site
Form. Site Form(s) must be submitted with at least one Sponsor Form.
ADE Staff Use Only
For Sponsor/Site Entities:
Child Care Center
Non Public Organization
Adult Care Center
Private School
Faith Based
Tribal Group
Residential Treatment Center
Additional Site Entity Details:
Public vs Private (select one):
Profit Status (select one):
□Not for Profit
□Public
□Private
□For Profit
Notes:
Note to Program Staff: For brand new entities, please ensure proper documentation is submitted to Entity Manager or the entity cannot
be created.
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