Appendix C - Application Cover Page and Contact Information

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LEA Applicant Information

Name of LEA Applicant *

Mailing Address *

City *

State *

Zip *

CD/CDS Code *

County *

LEA Contact Information - Person authorized to sign grant award agreement

Name of LEA Signatory *

Title *

Telephone Number *

Email Address *

LEA Contact Information - Person responsible for day-to-day grant management

Name of LEA Contact Person *

Title *

Telephone Number *

Email Address *

LEA Fiscal Agent Information - Person responsible for grant budget oversight

Name of Fiscal Agent *

Title *

Agency *

Mailing Address *

City *

State *

Zip *

Telephone Number *

Email Address *

Consortium

Is this a consortium application *
Yes
No

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