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4l'OHREORC I! <br />1V�I:STNI;lP <br />B<111UY <br />AGENCY EXPERIENCE VERIFICATION FORM <br />D. REPORT AUTHORIZATION <br />Authorized Signature of Funding Agency <br />Name of Authorized Signatory of Funding Agency <br />Telephone Number Fax Number <br />D. REPORT VERIFICATION <br />Date <br />Date <br />E -mail Address <br />SAWIB Staff Signature Verifying Report SAWIB Staff Name Date <br />Telephone Number Fax Number E -mail Address <br />RFP RESPONDENT'S AUTHORIZATION TO RELEASE INFORMATION: <br />On behalf of my organization, I am authorizing the funding agency named in line B to release the <br />information requested on this AGENCY EXPERIENCE VERIFICATION and any other information that <br />will aid City of Santa Ana Workforce Investment Board /Youth Council in evaluating our <br />demonstrated ability in operating youth programs. All information so released will become part of a <br />public document, subject to review and inspection by the public at the City's discretion, in <br />accordance with the Public Records Act. <br />Authorized Signature of Respondent /Agency <br />Name of Authorized Signatory <br />Telephone Number <br />Fax Number <br />19D-40 <br />Date <br />Date <br />E -mail Address <br />Page 2 of 2 <br />36 <br />