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6. Attach documentation of internal controls, conflict of interest, and firewall policies. <br />Signature Page <br />By signing below, the local CEO and Local Board chair request approval from the Governor to be <br />an Adult and Dislocated Worker Career Services Provider. Each party certifies that this <br />application submission was reviewed and demonstrates that the Local Board or administrative <br />entity will meet all the requirements as an Adult and Dislocated Worker Career Services <br />Provider under WIOA law and regulations. <br />Instructions <br />The Local Board chair and local CEO must sign and date this form. Include the original <br />signatures with the request. <br />Local Workforce Development Board <br />Chair <br />Signature <br />Daisy Campos <br />Name <br />Chair —Santa Ana WDB <br />Title <br />j 1 tsZ - 2 c) Z `� <br />Date <br />Local Chief Elected Official <br />Signature <br />Valerie Amezcua <br />Name <br />Mayor — City of Santa Ana <br />Title <br />Date <br />Page 7 of 7 <br />