Please complete the blank form on Page 3 assigning staff names to each function. A staff member may have authority in multiple areas. Please mail the completed document, signed by the Executive Director, to Tom Stephens, DHCD, 600 E. Main St, Suite 300, Richmond VA 23219. We would appreciate your effort to mail it on or before 5/17/11. EXAMPLE of how form should be completed: ABC Community Action Agency, Inc 123 Main Street, Suite 456 Anytown, VA 12345 Name/Title/Contact System Client Wx job Financial Reviewer Number/Email Administrator management/ coordinator and intake invoicing Paul Pillsbury, Weatherization X X X Program Mgr.; 804-555-1213; Kasey Kellogg, Financial Officer; X 804-555-1214; Harry Hunt, Executive Director; X 804-555-1111; Barksdale, Intake Specialist; X 804-555-1215; bbarksdale@abcaa.org Jimmy Jones, Weatherization X Inspector; 804-555-1216; jjones@abcaa.org Harry Hunt AGENCY APPROVAL: Harry Hunt, Ex. Director 5-17-11 Date WAP ONLINE USER AUTHORIZATION FORM Subgrantee Agency Name and Address:
Please complete the blank form on Page 3 assigning staff names to each function. A staff member may have authority in multiple areas. Please mail the completed document, signed by the Executive Director, to Tom Stephens, DHCD, 600 E. Main St, Suite 300, Richmond VA 23219. We would appreciate your effort to mail it on or before 5/17/11. EXAMPLE of how form should be completed: ABC Community Action Agency, Inc 123 Main Street, Suite 456 Anytown, VA 12345 Name/Title/Contact Number/Email System Administrator Client management/ intake Wx job coordinator Financial and invoicing Reviewer Paul Pillsbury, Weatherization Program Mgr.; 804-555-1213; X X X Kasey Kellogg, Financial Officer; 804-555-1214; X Harry Hunt, Executive Director; 804-555-1111; X Barksdale, Intake Specialist; 804-555-1215; bbarksdale@abcaa.org X Jimmy Jones, Weatherization Inspector; 804-555-1216; jjones@abcaa.org X AGENCY APPROVAL: Harry Hunt Harry Hunt, Ex. Director 5-17-11 Date WAP ONLINE USER AUTHORIZATION FORM Subgrantee Agency Name and Address: