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Dyslexia Grant
Cover Page
Appendix C - Cover Page
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Applicant Information
Name of IHE/LEA Applicant:
*
Mailing Address:
*
City:
*
State:
*
Zip:
*
CD/CDS Code for LEA:
*
Contact Information
Name of IHE/LEA Contact Person:
*
Title:
*
Telephone:
*
Email:
*
Alternate Contact Information
Name of Alternate IHE/LEA Contact Person:
*
Title:
*
Telephone:
*
Email:
*
IHE/LEA Fiscal Agent Information
Name of Fiscal Agent:
*
Agency:
*
Mailing Address:
*
City:
*
State:
*
Zip:
*
Telephone:
*
Email:
*
Administrative Approval for the IHE/LEA
Name of Dean, Superintendent, or Authorized Administrator:
*
Title:
*
