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2017 Signature Authorization Form 40" <br /> Effective January 1, 2017 through December 31, 2017 Snohomish County <br /> Human Services <br /> Submit completed original form to: <br /> Snohomish County Human Services, Attn: HSD Contracts, 3000 Rockefeller, M/S 305, Everett, WA 98201 <br /> Please print or type clearly all names and sign in blue ink. <br /> SECTION 1: Official Business Name of Organization <br /> Business Name: City of Everett/Carl Gipson Senior Center Date Submitted: 10/16/17 <br /> 2930 Wetmore Ave 10th Floor <br /> Mailing Address: Everett WA 98201 <br /> Street City State Zip <br /> SECTION 2: Authorizing Authority <br /> Signature Print or Type Name Title <br /> atv Ray Stephanson Mayor, City of Everett <br /> SECTION 3: Authorization to Sign Contracts/Contract Amendments <br /> Signature Print or Type Name Title <br /> taftja Ray Stephanson Mayor, City of Everett <br /> SECTION 4: Authorization to Sign Invoices/Requests for Reimbursements <br /> Signature Print or Type Name Title <br /> b. Bob Dvorak Director, Senior Center <br /> .��- Eric Wollan Senior Center Coordinator <br /> '��•: '' Lisa Harrison Senior Center Admin <br /> SECTION 5: Contract Delivery Designation <br /> Email Address Print or Type Name Title <br /> bdvorak@everettwa.gov Bob Dvorak Director, Senior Center <br /> ewollan@everettwa.gov Eric Wollan Senior Center Coordinator <br /> lharrison@everettwa.gov Lisa Harrison Senior Center Admin <br /> Revised 11/9/16 <br />