Appendix C - Cover Page

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Applicant Information

Name of IHE/LEA Applicant: *

Mailing Address: *

City: *

State: *

Zip: *

CD/CDS Code for LEA: *

Contact Information

Name of IHE/LEA Contact Person: *

Title: *

Telephone: *

Email: *

Alternate Contact Information

Name of Alternate IHE/LEA Contact Person: *

Title: *

Telephone: *

Email: *

IHE/LEA Fiscal Agent Information

Name of Fiscal Agent: *

Agency: *

Mailing Address: *

City: *

State: *

Zip: *

Telephone: *

Email: *

Administrative Approval for the IHE/LEA

Name of Dean, Superintendent, or Authorized Administrator: *

Title: *

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