HomeMy WebLinkAbout*Other - Renew (002)1VO&IS10111 stale DqA10ftwill of
Health
Behavioral Health Agencies
P.O. Box 47877
Olympia, WA 98504-7877
360-236-4700
Revter/ nue:0597649550
Iq
Administrator Chan-ge Notification Form
Behav 'ioral Health Agency Service Provide]
Name of Agency:
Grant Integrated Services - Quincy
Credential Num- ber
BHA. FS. 60872652
As the newly appointed Administrator of the above agency, I affirm that I am responsible for perfor ing '
M tie ke y
responsibilities as of the date I was appointed Administrator.
New Administrator Name:
Title�
Dell Anderson
Executive Director
NeyvAdministratorSr'n!atLure
Date of Sioature
2/18/2021
Date Appointed: Administrator's Email.- Administrator's Telephone:
10/19/2019 daan.d.lerson@geantcountywa.gov -509-,764-26,44
Printed Name of Governing Body Member Submitting Form: Title:
Cindy erT Chair of the Board of Commissioners
qnat4e: Date of Signature:
U.
Mailing Address:
P.O. Box 37
City
State
Zip Code
Ephrata
WA
98837
Email:
Phone-,
Fax:
commissioners@grantcountywa.gov
509-754-2011 Ext, 2901
509-754-6098
Within 30 days of the Administrator'sintment,.Send the following to the address listed above:
appol
12 This completed form.
• Criminal background check results, completed by Washington State Patrol within the last 365 days.
• The printout of the search at http-;//exclusions.oi-ci..hhs.gov/.
";t R L
E C
WE
DOH 611-006 July 2018 FEB 19 2021
GRANT COUNTY COMMISSIONERS
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