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V Health
Behavioral Health Agencies
P.O. Box 47877
Olympia, WA 98504-7877
360-236-4700
Revenue: 059764.9550
W4 10
Administrator Change Notification Form
Behavioral Health A
I gency Service Providell
- -----------
Name of Agency:
Grant Integrated Services - Royal City
Credential Number
BHA..FS.60872653
As'the 66 y'-';ap'p6-1nted Ad'm'.'in'--1 --- strator of the above agency, I affirtft that I a responsible for' erfo mi g the key
m respo p� r n
res ponsibiltitle s as of the date I was appointed Administrator.
New Administrator Name:
Dell.Anderson
NewFd�:tnistrator Stgn*ure
Date' A—poointed:
10119/2019
Administrator's Email:
daanderson@grantcountywa.gov
------------
Printed Name of Governing Body Membe-r Submitting Form:
Cindy Ca
- ---- Signatvre: ------------
Ili Ili /IPI
Mailing Address-,
P.O. Box 37
City
Ephrata
Email:
commiss*loners@grantcountywa,.gov
Title,*
Executive Director
Date of Signature
2/1812021
Administrator's Telephone-,
509-764-2644
Title:
Chair of the Board of Commissioners
Date of Signature:
Zi
State Zip Code
WA 98837
Phone.- Fax-,
509-754-2011 Ext. 2901 509-754-6098
Within 30 days of the Admin i1strator$ s appointment, send the following to the address listed above:
2 This completed form.
• Criminal background check results, completed by Washington State Patrol within the last 365 days.
1
• The printout of the search at httg,://exclusions.oig,.bhsl.,g-o,.v/.
DOH 611-006 July 2018
REQ. -V
- -
FEB 1 9 9%1..021
1`F
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