Snohomish Health District 8/14/2017

CITY # SNOHOMISH HEALTH DISTRICT WWW.SNOHD.ORG Vital Records DATA-SHARING AGREEMENT FOR WEEKLY DEATH LIST CONTACT INFO: Organization: City of Everett Program: Para Transit Address: 3225 Cedar Street, Everett WA 98201. Contact Person: Brian Senyitko Phone: 425-257-8948 E-mail: bsenyitkoeverettwa.gov E-mail address for weekly use: pwelz@everettwa.gov DESCRIPTION OF USE: Please state the reason why the information is needed and how your program will be using the data: To keep customer data base updated CONDITIONS: • The Weekly Death List can be used only for the purpose stated above, cannot be used for commercial purposes, and will not be shared with other agencies, departments or programs. • There will be an annual fee of$744.09. Increases in the annual fee may occur due to changes in service costs. (Please enclose a check made payable to "Snohomish Health District" and send to: Vital Records, 3020 Rucker Ave., Suite 104 Everett, WA 98201.) • This will be an annual agreement and valid from July 1st through June 30th of the following year. • This agreement can be terminated with 14 days prior written notice. AGREEMENT: Receiving Agency: I agree that the information I have provided is true and correct to the best of my knowledge. I will use the data for the sole purpose stated above and will require all my users to comply with these conditions and res tions. Print Name: a T i . a �_ e ATT ST: Signature: ,f7111/M.,. . . Date: eith `'1 1, Arita D e es i��./ L Title: �/ -�-- - ICity lerk Sending Agency: The weekly death list will be e-mailed every Thursday to the e-mail address of the person that you have designated to receive the data. If you do not receive it by 5:00 PM on Thursdays, please call us at 425-3 9-5 50. ' Signature: C ��Z�t er>3 Date: S'-- 1E-17- Title: CA// oe r Lt fZ Peqktrzei. A' ROVED A TO ' 'M 7/11/2017 / ,/ MES • ILES,City Attorney