ADECONNECT REQUEST FOR ENTITY ADMINISTRATOR FORM.PDF
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Signature of Designated Official Signature of Authorized Representative November 2023 | Health and Nutrition Services | Arizona Department of Education | This institution is an equal opportunity provider. Request for ADEConnect Entity Administrator Account Complete and return this form to the Arizona Department of Education, Health & Nutrition Services. Upon receipt of this form, an ADEConnect Entity Administrator account will be created for the organization named above. The Entity Administrator will have authority to setup user accounts that will have access to CNPWeb and other Health & Nutrition Services online systems. If the Designated Official chooses to delegate the responsibility of creating ADEConnect user accounts for their organization, that individual must be identified in the second box below. All organizations must have at least one Entity Administrator. All designees must be an Authorized Representative on the Food Program Permanent Service Agreement. All email addresses must be to an individual email account, not an organization wide account. PLEASE SELECT ONLY ONE OPTION: Sponsor Entity Name/SFA Name: CTD Number: I am requesting to have an Entity Administrator Account Setup in my name: Designated Official Name: Designated Official Email Address: I am requesting to delegate Entity Administrator Authority to the individual named below: Authorized Representative Name: Authorized Representative Email Address: By signing below, I am authorizing the Arizona Department of Education, Health & Nutrition Services to create an ADEConnect Entity Administrator account for the organization named above. If I have delegated the Entity Administrator authority to another individual by checking the second box above, I understand that this person will be given full rights to establish user accounts for other users and these accounts may have access to submit claims for reimbursement or other sensitive information. I further acknowledge that the information above is true and correct. Complete, sign, and email this form to: HealthandNutrition@azed.gov Printed Name of Designated Official Printed Name of Authorized Representative Date Date Maricopa County Human Services Head Start 072631 Lou Anne Liguz louanne.liguz@maricopa.gov Cami Foulks Lou Anne Liguz