HomeMy WebLinkAboutExhibit 4HEALTH
Bureau of Child Nutrition Programs
Child Care Food Program
BOARD OF DIRECTORS CERTIFICATION
(Not-For-Profi( Independent Child Care Centers, Affiliated Sponsoring Organizations of Child Care Centers,
Affiliated Afterschool Snack Programs, and Homeless Child Nutrition Program Contractors Only)
rization Number:
I certify that the following are the board members for
Name of Organization
i nq a list of board members, it must include addresses and phone numbers and you must still complete the last two columns below and sign the back of this form.
'
e of Board Member.:
Position
Board
- • ...•
Pinanca
Interest in•
..,(ginployee of Org.
,.".•.Center,
...Yes/No •
• .
Family
Relationship
to Other Bonrt•l
• Ittiembers
Yes/No
r's