4040-0003 SF-424 Short organizational

SF-424 Short Organizational (Short)

SF-424 S mock-up

DOI SF-424 Short Organizational Burden Estimate

OMB: 4040-0003

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OMB Number: 4040-0003

Expiration Date:


APPLICATION FOR FEDERAL DOMESTIC ASSISTANCE - Short Organizational

* 1. NAME OF FEDERAL AGENCY:



2


. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:



C


FDA TITLE:


* 3. DATE RECEIVED: SYSTEM USE ONLY

*


4. FUNDING OPPORTUNITY NUMBER:



*


TITLE:


5. APPLICANT INFORMATION

*


a. Legal Name:


b. Address:

*


Street 1:


S


treet 2:


*


City:


C


ounty / Parish:


*


State:


P


rovince:


* Country:



*


Zip/Postal Code:


c. Web Address:

h


ttp://

*


d. Type of Applicant: Select Applicant Type Code(s):



T


ype of Applicant:



T


ype of Applicant:



*


Other (specify):


* e. Employer/Taxpayer Identification Number (EIN/TIN):



*


f. Organizational DUNS:


*


g. Congressional District of Applicant:


6. PROJECT INFORMATION

*


a. Project Title:


*


b. Project Description:


c



. Proposed Project: * Start Date * End Date:



OMB Number: 4040-0003

APPLICATION FOR FEDERAL DOMESTIC ASSISTANCE - Short Organizational

7. PROJECT DIRECTOR




P



refix: First Name:


M


iddle Name:


*


Last Name:


S


uffix:


*


Title:


*


Email:


*


Telephone Number:


F


ax Number:


*


Street1:


S


treet2:


*


City:


C


ounty / Parish:


*


State:


P


rovince:


*


Country:


*


Zip/Postal Code:


8. PRIMARY CONTACT/GRANTS ADMINISTRATOR

Same as Project Director (skip to item 9):


P



refix: * First Name:


M


iddle Name:


*


Last Name:


S


uffix:


*


Title:


*


Email:


*


Telephone Number:


F


ax Number:


*


Street1:


S


treet2:


*


City:


C


ounty / Parish:


*


State:


P


rovince:


*


Country:


*


Zip/Postal Code:










OMB Number: 4040-0003

APPLICATION FOR FEDERAL DOMESTIC ASSISTANCE - Short Organizational

9. * By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties (U.S. Code, Title 218, Section 1001)

** I Agree

** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency specific instructions.

AUTHORIZED REPRESENTATIVE

P



refix: * First Name:


M


iddle Name:


*


Last Name:


S


uffix:


*


Title:


*


Email:


*


Telephone Number:


F


ax Number:


* Signature of Authorized Representative:


* Date Signed:



File Typeapplication/msword
File TitleOMB Number: 4040-0003
AuthorCan Varol
Last Modified ByAdministrator
File Modified2008-06-16
File Created2008-06-16

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