Appendix C - Cover Page

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LEA Applicant Information

Name of LEA Applicant *

Mailing Address *

City *

State *

ZIP *

CD/CDS Code *

Contact Information (Person responsible for day-to-day grant oversight)

Name of LEA Contact Person *

Title *

Telephone *

Email *

Contact Information (Person authorized to sign grant award agreement)

Name of LEA Signatory *

Title *

Telephone *

Email *

LEA Data Agent Information (Person responsible for grant data oversight)

Name of Data Agent *

Title *

Telephone *

Email *

LEA Fiscal Agent Information (Person responsible for grant budget oversight)

Name of Fiscal Agent *

Agency *

Telephone *

Email *

Consortium application?

List all partner LEA(s). A Partnership Agreement (Appendix F) is required for each consortium member listed. If not applying as a consortium, leave blank.

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