Cleaning Supplies Self-Certification Agreement


I understand, as a provider, that this self-certification form is a requirement to receive CSCP funds, supplies, or both to serve essential workers and/or at-risk populations during the COVID-19 pandemic. As stated on this form, my program currently is open or will be open by the date specified and the funds and/or supplies will be used solely for these restricted purposes.

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Signature Certificate
Document name: Cleaning Supplies Self-Certification Agreement
lock iconUnique Document ID: 9ce290299922ef6464e4b1ac0edd59596a5af90a
Timestamp Audit
May 4, 2020 2:48 pm PDTCleaning Supplies Self-Certification Agreement Uploaded by Valeria Cisneros - [email protected] IP 67.170.203.189
May 4, 2020 3:21 pm PDTValeria Cisneros - [email protected] added by Valeria Cisneros - [email protected] as a CC'd Recipient Ip: 174.238.4.226
May 4, 2020 3:28 pm PDTValeria Cisneros - [email protected] added by Valeria Cisneros - [email protected] as a CC'd Recipient Ip: 174.238.4.226
May 4, 2020 3:28 pm PDTValeria Cisneros - [email protected] added by Valeria Cisneros - [email protected] as a CC'd Recipient Ip: 174.238.4.226
May 4, 2020 3:32 pm PDTValeria Cisneros - [email protected] added by Valeria Cisneros - [email protected] as a CC'd Recipient Ip: 174.238.4.226
May 4, 2020 3:32 pm PDTValeria Cisneros - [email protected] added by Valeria Cisneros - [email protected] as a CC'd Recipient Ip: 174.238.4.226
May 4, 2020 3:38 pm PDTValeria Cisneros - [email protected] added by Valeria Cisneros - [email protected] as a CC'd Recipient Ip: 67.170.203.189
May 4, 2020 4:59 pm PDTValeria Cisneros - [email protected] added by Valeria Cisneros - [email protected] as a CC'd Recipient Ip: 67.170.203.189
May 4, 2020 4:59 pm PDTCleaning Funds - [email protected] added by Valeria Cisneros - [email protected] as a CC'd Recipient Ip: 67.170.203.189