HICAP COUNSELOR EXIT NOTICE by eddie12

VIEWS: 9 PAGES: 1

									HICAP COUNSELOR EXIT NOTICE
FROM: ______________________________
Name of Program Manager (Print or Type)

PSA#_________

The HICAP Counselor named below is no longer affiliated with the HICAP for the following reason(s): The Counselor resigned from the HICAP. Please send a letter of appreciation to (optional): Name: Street Address: City: State:

Zip Code:

The Counselor has been decertified. Do NOT send a letter of appreciation. The Counselor is deceased (Local HICAP is responsible for condolence and/or appreciation letter). Other: Please specify Please remove this individual from the CDA Counselor Registration List effective date. Effective Date:
Mo

/
Day

/
Yr

Name of Counselor:

Signed:

________________________________ HICAP Program Manager
1)

Date:

Instructions:

Prior to submitting HICAP Counselor Exit Notice, E-mail notification of submission to Support Staff and Assigned Analyst.

2)

Mail original HICAP Counselor Exit Notice via US Postal. Do NOT Fax. Mailing Address: California Department of Aging Attn: HICAP Registration 1300 National Drive, Suite 200 Sacramento, CA 95834-1992
6cb21630-c29d-4e04-badc-91cc8dcdd712.rtf
REV. 06/2008


								
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