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Integrated Program Implementation and Expansion Grant
Cover Page
Appendix C - Cover Page
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IHE Applicant Information
Name of IHE
*
Mailing Address
*
City
*
State
*
ZIP
*
IHE Primary Contact Information - Person responsible for day-to-day grant management
Name
*
Title
*
Mailing Address
*
City
*
State
*
ZIP
*
Telephone
*
Email
*
IHE Contact Person authorized to sign Grant Award Agreement (GAA)
Name
*
Title
*
Mailing Address
*
City
*
State
*
ZIP
*
Telephone
*
Email
*
IHE Fiscal Agent Information – Person responsible for grant budget oversight
Name
*
Title
*
Mailing Address
*
City
*
State
*
ZIP
*
Telephone
*
Email
*