Application Cover Sheet

Organizational Information

1.Applying Agency Name

2.Agency EIN Number

3.Agency Unique Entity ID (from SAM.gov)

4.Type of Organization (i.e. 501(c)3)

5.Date of Incorporation

6.Mailing Address

7.Street Address (if different than above)

8.Website Address

9.Individual Applicant Name

10.Individual Applicant Title

11.Individual Applicant Email Address

12.Individual Applicant Phone Number