County of San Diego - Download as DOC

							                                                                     County of San Diego
                                                            Office of Emergency Services
                                                              Signature Authorization Form
                                                                Homeland Security Grant



For Jurisdiction:                                                                                          Date Signed:


The below named personnel are authorized to request for reimbursement for the following Homeland Security Grant Programs includes State Homeland
Security Grant Program (SHSGP), Law Enforcement Terrorism Prevention Program (LETPP), Urban Area Security Initiative (UASI), Citizen Corps
Program (CERT), Emergency Management Performance Grant (EMPG) and Pre-Disaster Mitigation Competitive Grant Program (FEMA).

                NAME                             SPECIMEN                    TELEPHONE                          E-MAIL ADDRESS
           (TYPED/PRINTED)                      SIGNATURE                     NUMBER




This form supersedes all others for above indicated jurisdiction. NOTE: Requests for reimbursement received from staff not identified in this form
will not be processed.


Printed Name:                                    Signature:                                                      Phone Number:


Mail form to County Office of Emergency Services, 5555 Overland Avenue Suite 1911 MS O25, San Diego, CA 92123
For questions on this form, please contact Ardath DeRose at (858) 715-2208 or Ardath.DeRose@sdcounty.ca.gov.



Jan 2010