Appendix C - Cover Page

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Carefully read and follow the directions on the website to complete the form and generate a PDF version that can be attached to the final application. All narrative responses and PDF appendices must be submitted as one application. This form should be the cover page to the application submitted to the Commission.

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

Name of Data Agent

Title

Telephone

LEA Fiscal Agent Information (Person responsible for grant budget oversight)

Name of Fiscal Agent *

Agency *

Telephone *

Email *

LEA Administrative Approval

Name of Superintendent of Authorized Administrator *

Title *

Email *

Consortium Application

If yes, indicate all LEA consortium members.

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