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Arizona Department of Education Health & Nutrition Services Request for ADEConnect Entity Administrator Account Sponsor Name: Maricopa County Human Services Head Start CUD #: 072631 Complete and return this form to the Arizona Department of Education, Health & Nutrition Services. Upon receipt of this form an ADECormect, 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 the CNP Web 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 Permanent Food Service Agreement. All email addresses must be to an individual email account, not an organization wide account. 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: Chrisanda DeBois Authorized Representative Email Address: deboisc@mail.maricopagov By signing below, I am authorizing the Arizona Department of Education, Health & Nutrition Services to create an ADEConneet 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,t.rue and correct. Bruce Liggett Printed Name of Designated Official Signature of Designated Official Date Chrisanda DeBois Chrisanda DeBois Printed Name of Authorized Representative Signature of Authorized Representative Date Complete and email this form to: healthandnutrition(a),azed.gov 8/10/17 8/10/17 This institution is an equal opportunity provider.