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SAMPLE <br />Designation of Agent Form <br />As the County Manager of Carolina , I appoint the <br />following person <br />Name: James Taylor <br />Title: County Emergency Manager <br />Address: 1 County Place <br />City & Zip: Sandersonville, NC 27999 <br />Telephone: 919/5 5 5-67 89 <br />Fax: 919/555-6788 <br />Email: jtaylor(a nc.cc.org <br />to be my Designated Agent for the DHS FY2003 SHSGP. The above-listed person may sign and <br />submit documents related to this grant. <br />Restrictions (If none, write none): vio~vtei <br />~LarY 9ones 8/T/03 <br />County Manager's Signature Date <br />NCEM recommends that the County Emergency Manager <br />be identified as the Designated Agent. <br />This form must be returned to the DHS FY2003 SHSGP Manager no later than August 29, <br />2003. <br />15 <br />DHS FY2003 SHSGP Memorandum of Aereement Annex B: Designated Agent and POC Page 3 of 5 <br />