HomeMy WebLinkAboutF_GrantDocumentsAuthorizedSigners5_IPGrant Documents Authorized Signers
Please clearly print or type all sections of this form.
Community/Grantee Name: Independence Power, LLC
Regular Election is held: NA Date: NA
Authorized Grant Signer(s):
W
Printed Name
Title
Term
S' n ure
David Ausman
Member, Project
Manager
NA
Joel Groves
Member, Alt. Project
Manager
NA
I authorize the above person(s) to sign Grant Documents:
(Highest ranking organization/community/municipal official)
Printed Name
Title
Term
Si u e
David Ausman
Member, Project
Manager
NA
Grantee Contact Information:
Mailing Address:
1503 West 33'0 Avenue #310
Anchorage, AK 99503
Phone Number:
907-258-2420 x202
Fax Number:
907-258-2419
E-mail Address:
dave@polarconsult.net
Fiscal Year End:
December 31
Entity Type (For -prof it or non -prof it status):
For -profit
Federal Tax ID #:
26-4393105
Please submit an updated form whenever there is a change to the above information.
Please return the original completed form to:
Alaska Energy Authority
813 W. Northern Lights Blvd. /C::D X9- KA
Anchorage, AK 99503 ENERGY AUTHORITY
Attn: Butch White, Grants Administrator
Z:\network\Jobs\lndPWr-4thJulyCrk(08011)\Funding\FY13-AEA\F_AuthSignersForm\F_GrantDocumentsAuthorizedSigners5_I P.doc