PAGE 2                                                                                                                                                                                                                                WEEB 1

        CONSORTIUM VERIFICATION FORM
Electronic versions available on website

 

 

 

Each of the undersigned certifies that they will participate in this project, that the specified obligations and responsibilities in this project will be met, and that the project will be administered by the public agency or corporation designated.

 

 

                                                                                                  ADMINISTERING ORGANIZATION

 

Organization’s Name

 

Black Rock School District

Project Director’s Name

Faith Jardiner

Project Title

 

From Black Rock to Eden: Transformations through gardening and growing

Telephone Area/No

(715) 222-2222

 

 

                                                                                               PARTICIPATING ORGANIZATION(S)

 

 Organization’s Name

Black Rock Master Gardeners

 

Telephone Area/No.

(715) 222-3333

Address (Street, City, State, Zip)

2002 Earth Lane, Titletown WI 54000

Supplying 1/3 or More of the Total Match?
(If yes, then CEO must sign.)
  Yes                                  o No

Name and Title

Caroline Anemone, Executive Director

 

Signature

Ø Caroline Anemone

Date Signed
12/6/2005

 Organization’s Name

Black Rock Parent Teacher Organization

 

Telephone Area/No.
(715) 222-4444

Address (Street, City, State, Zip)

3003 Reinforcement Drive, Titletown WI 54000

Supplying 1/3 or More of the Total Match?
(If yes, then CEO must sign.)
o Yes                                    No

Name and Title

Brooke Waters, President

 

Signature

Ø Brooke Waters

Date Signed
12/6/2005

 Organization’s Name

Black Rock Summer Club

 

Telephone Area/No.

Address (Street, City, State, Zip)

4004 Handup Way, Titletown WI 54000

Supplying 1/3 or More of the Total Match?
(If yes, then CEO must sign.)
o Yes                                    No

Name and Title

Reginald Gateway, Team Leader

 

Signature

Ø Reginald Gateway

 

Date Signed
12/8/2005

 Organization’s Name

 

PlantWell Nursery

Telephone Area/No.

Address (Street, City, State, Zip)

5005 Tendme Lane, Titletown WI 54000

Supplying 1/3 or More of the Total Match?
(If yes, then CEO must sign.)
o Yes                                    No

Name and Title

Maxine Handrich, Owner

 

Signature

Ø Maxine Handrich

Date Signed
12/14/2005
     

 

Use a duplicate of this form if there are more than four participating organizations.