| Name of agency adopting document . . . . . . . . . . . . |
Contact person, if other than
responsible official . . . . . . . . . . . . . |
Phone . . . . . . . . . . . . |
| Responsible official . . . . . . . . . . . . |
| Position/title . . . . . . . . . . . . . . . . . . | Phone . . . . . . . . . . . . |
| Address . . . . . . . . . . . . |
| Date . . . . . . . . . . . . | Signature . . . . . . . . . . . . |