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<br />ACCOUnlrt <br /> <br />GENERAL SERVICES COMMISSION <br />INTER-GOVERNMENTAL PROGRAMS <br />FEDERAL SURPLUS PROPERTY PROGRAM <br />, AUTHORIZED REPRESENTATIVES f <br /> <br />LEGAL NAME & MAILING ADDRESS OF APPLICANT ORGANIZATION: <br /> <br />.Vame Of OrganlZ8DDn <br /> <br />.:J'1reer Addms$ <br /> <br />'.fs///m; Adc1rsss (p.Q Box If, S/rser. '-~N" Sls/l" <br /> <br />(9 DigIt ZI" C""el <br /> <br />";~unty <br /> <br />7eleonone " <br /> <br />THE FOLLOWING REPRESENTATIVES ARE DESIGNATED TO: <br /> <br />4. Ae,JreS8nr Oonse Organization as IS ItS aultJorlzea agent: ana <br /> <br />3. ACQUIre Federal surD/US Drooerry on behalf of the Donee Orgamzatlon: and <br /> <br />C. Obligate nec&ssaJy Donee OrgantzaIlon (unas (or /hIS PUrpose: ana <br /> <br />O. ExflCute Distnbu/Jon Documents bmamg /he Donee Organ/ZJJ/lon 10 me lerms. conaltlons. reservstlOflS. <br />and resrnctians applying 10 Property obtamea througn Ihe agancy. <br /> <br />~ NEW DESIGNATIONS <br />(De/8'" 81/ PnMOUS 8UlhOllZJlllOnl <br /> <br />OR <br /> <br />.= ADDITIONAL DESIGNATIONS ONLY <br />(Add to DfW10Us 8uthonz8DOnJ <br /> <br />IV, REPRESENTAnVES: <br /> <br />Name <br /> <br />iitlll <br /> <br />TB/8pnOlle <br /> <br />Signarurs <br /> <br />V. CERTTFICATION (Don.. amnns that nama a,.. cummt/comH:t). <br /> <br />D6IW <br /> <br />PnnMt1 N_ at ~ 0Ifft:JW <br /> <br />Tille <br /> <br />~ at AutI1ak-. 0Ifft:JW <br />