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* 1. Organization Name/ Site Location:

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* 2. Organization Address:

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* 3. Primary Point of Contact Name:

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* 4. Primary Point of Contact Role:

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* 5. Primary Point of Contact Phone Number:

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* 6. Primary Point of Contact Email:

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* 7. What ACENet Program(s) are you interested in?

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* 8. Do you have a Classroom and a Lab Space to host bootcamps and house equipment?

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* 9. Do you have administrative staff to support the ACENet Program at your site?

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* 10. Do you have faculty members who will provide instruction during the Bootcamps?

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* 11. Participation/Bootcamp Description. Example: A minimum of 6 bootcamps per year with 10 participants per camp, serving 60-100 annually

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* 12. What is the current inventory of equipment that will be used to support the program (Industrial CNC mills, 3D printers, etc.)?

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* 13. Budget- Rough order of Magnitude (ROM): A rough estimated total budget of $__________ (Not including any leveraged funds) would be needed to complete the objectives described above. This budget would be spent over ________ years and includes $_________ in equipment.

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* 14. List of top 5 - 10 supporting employers within your service area. Please note if any are directly supporting DOD Contracts (If known)

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* 15. Optional Potential benefits to the U.S. Department of Defense Industrial Base Analysis and Sustainment Program and Industry:

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