DESIGNATE APPLICANT AGENT WITH HMA -MCDPH.PDF

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
Maricopa County Department of Public Health
Clint Hickman
Chairman
Maricopa County Board of Supervisors
Maricopa County Board of Supervisors
Maricopa County Department of Public Health
25
March 
2020
Mitchell Lach
Maricopa County Department of Public Health
SIGN
Chairman
Mitchell Lach
Division Administrator, Disease Control
4041 N Central Avenue, Suite 600
mitchell.lach@maricopa.gov
602-372-2657
602-725-7189