Appendix C - Cover Page

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IHE Applicant Information

Name of IHE *

Mailing Address *

City *

State *

ZIP *

IHE Primary Contact Information - Person responsible for day-to-day grant management

Name *

Title *

Mailing Address *

City *

State *

ZIP *

Telephone *

Email *

IHE Contact Person authorized to sign Grant Award Agreement (GAA)

Name *

Title *

Mailing Address *

City *

State *

ZIP *

Telephone *

Email *

IHE Fiscal Agent Information – Person responsible for grant budget oversight

Name *

Title *

Mailing Address *

City *

State *

ZIP *

Telephone *

Email *

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