Appendix C - Application Cover Page and Contact Information

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Applicant Information

Name of LEA Applicant: *

Mailing Address: *

City: *

State: *

Zip: *

CD/CDS Code: *

Contact Information (Person responsible for day-to-day grant oversight)

Name of LEA Contact Person: *

Title: *

Telephone: *

Email: *

Contact Information (Person authorized to sign grant award agreement)

Name of LEA Signatory: *

Title: *

Telephone: *

Email: *

LEA Fiscal Agent Information

Name of Fiscal Agent: *

Agency: *

Telephone: *

Email: *

LEA Data Agent Information(Person responsible for grant data oversight)

Name of Data Agent *

Title *

Telephone *

Email *

Signatory Information

Name of Superintendent of Authorized Administrator: *

Title: *

Email: *

Consortium

Consortium Application

If yes, indicate all LEA consortium members

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