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

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

Form Details:

  • The latest edition currently provided by the Arizona Department of Education;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Arizona Department of Education.

ADVERTISEMENT
ADVERTISEMENT

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

Download PDF

Fill PDF online

Rate (4.5 / 5) 12 votes
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
Tribal Group
Residential Treatment Center
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
Tribal Group
Residential Treatment Center
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.
Site Form
(To be included when requesting action for one or more sites)
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
Adult Care Center
Non-Public Organization
Private School
Faith Based
Tribal Group
Residential Treatment Center
Additional Site Entity Details:
Public vs Private (select one):
Profit Status (select one):
□Public
□Private
□For Profit
□Not 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.
Page of 2