Agreement with Az Department of Emergency & Military Affairs

ARIZONA DEPARTMENT OF EMERGENCY AND MILITARY AFFAIRS 
DESIGNATION OF APPLICANT’S AUTHORIZED REPRESENTATIVE FORM 
The intent of this DESIGNATION is to appoint an APPLICANT’S AUTHORIZED REPRESENTATIVE 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 Authorized Representative 
(Name of Designated Applicant's Authorized Representative) 
to act on behalf of 
. 
(Applicant) 
(Authorizing Official’s Signature) 
(Title) 
(Date) 
Designated Applicant’s Authorized Representative 
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: ______________________       
 November 2023       
     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 Authorized Representative.
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
26
March
2024
Emergency Manager
City of Glendale
SIGN
City Manager
Emergency Manager
11550 W Glendale Ave, Glendale, AZ 85307
nmunson@glendaleaz.com
623-872-5023
623-633-3214



Nicole Munson

AZDEMA Designation of Applicant’s Authorized Representative 
Arizona Department of Emergency & Military Affairs 
 
 
 
 
City of Glendale Signature Page 
 
 
 
 
ATTEST: 
 
 
 
______________________________________ 
Julie K. Bower, City Clerk 
 
(Seal) 
 
 
APPROVED AS TO FORM:  
 
 
 
______________________________________ 
Michael D. Bailey, City Attorney