Form 424 Short Organizational

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APPLICATION FOR FEDERAL DOMESTIC ASSISTANCE - Short Organizational

About
OMB Number: 4040-0003
Expiration Date: 01/31/2007
Version 01

* 1. NAME OF FEDERAL AGENCY:

2. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:
CFDA TITLE:

* 3. DATE RECEIVED:

SYSTEM USE ONLY

* 4. FUNDING OPPORTUNITY NUMBER:
* TITLE:

5. APPLICANT INFORMATION
* a. Legal Name:
b. Address:
* Street1:

Street2:

* City:

County:

* State:

Province:

* Country:
USA: UNITED STATES

* Zip/Postal Code:

c. Web Address:
http://
* d. Type of Applicant: Select Applicant Type Code(s):

* e. Employer/Taxpayer Identification Number (EIN/TIN):

Type of Applicant:

* f. Organizational DUNS:

Type of Applicant:
* g. Congressional District of Applicant:
* Other (specify):

6. PROJECT INFORMATION
* a. Project Title:

* b. Project Description:

c. Proposed Project:

* Start Date:

* End Date:

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About
OMB Number: 4040-0003
Expiration Date: 01/31/2007
Version 01

APPLICATION FOR FEDERAL DOMESTIC ASSISTANCE - Short Organizational
7. PROJECT DIRECTOR
Social Security Number (SSN) - Optional:

000-00Disclosure of SSN is voluntary. Please see the application package instructions for the agency's authority and routine uses of the data.
Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

* Title:

* Email:

* Telephone Number:

Fax Number:

* Street1:

Street2:

* City:

County:

* State:

Province:

* Country:

* Zip/Postal Code:

USA: UNITED STATES
8. PRIMARY CONTACT/GRANTS ADMINISTRATOR
Social Security Number (SSN) - Optional:

000-00Same as Project Director (skip to item 9):

Prefix:

* First Name:

Disclosure of SSN is voluntary. Please see the application package
instructions for the agency's authority and routine uses of the data.
Middle Name:

* Last Name:

Suffix:

* Title:

* Email:

* Telephone Number:

Fax Number:

* Street1:

Street2:

* City:

County:

* State:

Province:

* Country:
USA: UNITED STATES

* Zip/Postal Code:

Close Form

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About
OMB Number: 4040-0003
Expiration Date: 01/31/2007

APPLICATION FOR FEDERAL DOMESTIC ASSISTANCE - Short Organizational

Version 01

9. * By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and
accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware
that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties (U.S. Code, Title 218, Section 1001)
** I Agree
** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions.
AUTHORIZED REPRESENTATIVE
Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

* Title:

* Email:

* Telephone Number:

Fax Number:

* Signature of Authorized Representative:

* Date Signed:

Authorized for Local Reproduction

Standard Form 424 Organization Short (04-2005)
Prescribed by OMB Circular A-102