California Public Utilities Commission
Local Agency Technical Assistance Program
CONSENT FORM
Acknowledgement and Acceptance of Terms
Applicant Name: _________________________________________________________ Key Project Contact: ______________________________________________________ The Grantee identified above acknowledges receipt of the California Public Utilities Commission Resolution T-__________ or Award Letter Dated__________ and agrees to comply with all grant terms, conditions, and requirements set forth in the Resolution or Approval Letter including those in the Local Agency Technical Assistance Rules.
Undersigned representative of ____________________________________ [Name of Grantee] is duly authorized to execute this Consent Form on behalf of the Grantee and to bind the Grantee to the terms, conditions, and requirements set forth in California Public Utilities Commission Resolution T-_____________ or Award Letter.
Dated this ______ day of ______________, 20___.
Signature of Local Agency/Tribe:
_______________________________________________________________________ Title____________________________________________________________________ Printed Name____________________________________________________________ ________________________________________________________________________ Organization or Name of Local Agency or Tribe:
________________________________________________________________________ Business Address (include street address, suite/apt. number, city, state, and ZIP Code):
_______________________________________________________________________ Telephone Number: ______________________________________________________ Email Address: ___________________________________________________________ Attachment 5