Agreement

ARIZONA DEPARTMENT OF EMERGENCY AND MILITARY AFFAIRS 
DESIGNATION OF APPLICANT’S AGENT FORM 
The intent of this DESIGNATION is to appoint an APPLICANT’S AGENT for the following: 
Applicant: 
CERTIFICATION 
I, 
, duly appointed and 
of 
(Authorizing Official’s Name) 
(Title) 
, do hereby certify that the information below is true and correct,
(Applicant)
based on a resolution passed and approved (attached) by the 
(Governing Body) 
of 
on the 
day of 
, 
. 
(Applicant) 
(day) 
(month) 
(year) 
 has been designated as the Applicant's Agent 
(Name of Designated Applicant's Agent) 
to act on behalf of 
. 
(Applicant) 
(Authorizing Official’s Signature) 
(Title) 
(Date) 
Designated Applicant’s Agent 
Cell  
Name   
Title/Official Position   
Full Mailing Address   
Email Address
Daytime Telephone Number 
(Please include area code and extension if not a direct number) 
Select program(s) 
Select duration
Public Assistance 
Until further notice        
Received By: ______________________       
 March 2020       
     Form #AZ PA 204-4 
   (Initials & Date) 
For DEMA Use Only
This document MUST be accompanied by a copy of  the Resolution or Meeting 
Minutes by your governing board which designated the Applicant's Agent.
HMA Mitigation Program 
Only Event _________ 
From _______ to ________
SEC Mitigation
City of Glendale
Kevin Phelps
City Manager
City of Glendale
Glendale City Council
City of Glendale
23rd
June
2023
Nicole Munson
City of Glendale
SIGN
City Manager
Nicole Munson
Emergency Manager
11550 W Glendale Ave, Glendale, AZ 85307
nmunson@glendaleaz.com
(623) 872-5023
(623) 633-3214



ATTEST: 
 
 
 
_______________________________________ 
Julie K. Bower, City Clerk 
 
(SEAL) 
 
 
APPROVED AS TO FORM: 
 
 
 
______________________________________ 
Michael D. Bailey, City Attorney