HomeMy WebLinkAboutUser Authorization Form41.1
ADAM H. PUTNAM
COMMISSIONER
Florida Department Of Agriculture and Consumer Services
Division of Food, Nutrition and Wellness
FLORIDA CHILD NUTRITION PROGRAM
USER AUTHORIZATION FORM
FY 2012-2013
Sponsor Name/Agency:
City of Miami Parks and Recreation
Phone Number:
(305)416-1308
Please type or print clearly the names of employees/administrators authorized to electronically view and/or submit Applications or Monthly Claims for Reimbursement
associated with participation in the federal Child Nutrition Programs -for the current fiscal year. Please note that Food Service Management Company (FSMC) employees are
not permitted access to the CNP Florida system. If you have a contract with a FSMC, please list the company name:
ACCESS REQUESTS
APACCE SON
ACCESS
VIEW
ONLY
ACCESS
DATE ID
SHOULD
EXPIRE
Staff Member
Access is granted per program
and not per agreementfor
number
01= =
NSLP,02=SMP,04SFSP/SSP
View ONLY
ALL
sponsor
data
Enter
only if
applicable
Name: John Nutrition
E-Mail: John.Nutrition@foodschool.org
01-0888
01-0999
04-0888
01-0888
Name: Lina Blanco
E-Mail:LinaB@miamigov. com -
Name: Juan Pascual
E-Mail: JPascual@miamigov. coin
Name: Donald Lutton
E-Mail: dlut ton@miamigov. com
Name: Gwendolyn Kitchen
E-Mail:GKitchen@ci.miami.fl.us
REMOVAL
REQUESTS
NAME:
REASON
(if applicable)
Ernest Burkeen
No longer employed
here
I hereby authorize the above users to access information on behalf of the sponsor ,noted above. I certify that the information on this form is true and correct to the best of my
knowledge. I understand that this information is being given in connection with receipt of federal funds; Department officials may, for cause, verify information; and deliberate
misrepresentation will subject me to prosecution under applicable federal and state criminal statutes. The SFA hereby agrees to comply with all state and federal laws and
regulations governing Child Nutrition Programs. The person signing below will ensure that all monthly claims for reimbursement represent meals/milk served by category and that
records are available to support these claims.
Type/Print Name of Authorized Party or Delegate
CITY MANAGER
Title of Authorized Party or Delegate
CITY MANAGER
agi tlR A horized Party or Delegate Date Signed
CITY MANAGER
Remit this form to your Program Area Representative via Fax (850) 617-7403
(Please list recipient name above)
DACS-01731 Rev. 03/12