PAGE 2                                                                                                                                                                                                                                WEEB 1

PRIVATE

        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

 

PRIVATE Organization’s Name

 

Sharington School District: Hope Elementary

Project Director’s Name

Penny Pound

Project Title

Food: Distribution and Utilization

Telephone Area/No

(999) 000-0000

 

 

                                                                                               PARTICIPATING ORGANIZATION(S)

 

PRIVATE  Organization’s Name

Hope Elementary Parent Teacher Organization

 

Telephone Area/No.

(999) 222-3333

Address (Street, City, State, Zip)

2002 Helping Hand Lane, Sharington WI 88888

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

Name and Title

Charolette Webster, President

 

Signature

Ø Charolette Webster

Date Signed
12/14/2006

PRIVATE  Organization’s Name

 

Telephone Area/No.

 

Address (Street, City, State, Zip)

 

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

Name and Title

 

Signature

Ø

Date Signed

 

PRIVATE  Organization’s Name

 

Telephone Area/No.

Address (Street, City, State, Zip)

 

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

Name and Title

 

Signature

Ø

 

Date Signed

 

PRIVATE  Organization’s Name

 

 

Telephone Area/No.

Address (Street, City, State, Zip)

 

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

Name and Title

 

Signature

Ø

Date Signed

 
     

 

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