Applicant Agency

Business Name	Click or tap here to enter text.	Street Address Including City, State, and ZIP Code	Click or tap here to enter text.
Contact Person	Click or tap here to enter text.	Title	Click or tap here to enter text.
Phone	Click or tap here to enter text.	Email	Click or tap here to enter text.
Authorized Representative	Click or tap here to enter text.	Title	Click or tap here to enter text.
Phone	Click or tap here to enter text.	Email	Click or tap here to enter text.
Federal Employer Tax Id #	Click or tap here to enter text.	Unique Entity Identifier #	Click or tap here to enter text.
Dates of Active Registration in System for Award Management	Click or tap here to enter text.
Targeted Intervention(s) to be Implemented	Click or tap here to enter text.
Total Amount of Funding Request	Click or tap here to enter text.
Willing to Accept Less Funding (Y/N)	Click or tap here to enter text.
Evidenced-Based Program/Services (Y/N)	Click or tap here to enter text.
Name and Source of Evidenced-Based Program/Services	Click or tap here to enter text.
School(s) or School District to be Served	Click or tap here to enter text.
Estimated Number of Youth to be Served	Click or tap here to enter text.
Estimated Number of Minority Youth to be Served	Click or tap here to enter text.

Signature	Name	Click or tap here to enter text.
Signature of the Person Submitting this Form	Name of the Person Submitting this Form (print)

Date of Signature	Click or tap here to enter text.