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CITY <br /> 2018 Signature Authorization Form ASOA <br /> Effective January 1, 2018 through December 31, 2018 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: Carl Gipson Senior Center Date Submitted: 01/29/2018 <br /> Mailing Address: 3025 Lombard Ave Everett WA 98201 <br /> Street City State Zip <br /> SECTION 2: Authorizing Authority <br /> ture — Print or Type Name Title <br /> Cassie Franklin Mayor <br /> SECTION 3: Authorization to Sign Contracts/Contract Amendments <br /> Si ture Print or Type Name Title <br /> Cassie Franklin Mayor <br /> io <br /> SECTION 4: Authorization to Sign Invoices/Requests for Reimbursements <br /> Signature Print or Type Name Title <br /> Bob Dvorak Director, Senior Center <br /> _Eric Wollan Senior Center Coordinator <br /> -- Lisa Harrison Senior Center Admin <br /> ,G�1 /; <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 /> Iharrison@everettwa.gov Lisa Harrison Senior Center Admin <br /> Rev. 11/7/17 <br />