State Programs - Information Update form

INFORMATION UPDATE
Submitted: ______________

DUNS Number:
STATE LIBRARY ADMINISTRATIVE AGENCY:
Mailing Address:
City:

State:

Zip:

Chief Officer of SLAA (Mr.)(Ms.)(Mrs.)(Other):
Title:
Phone Number:
Fax Number:
E-Mail Address:
Name of Parent Organization, if applicable (e.g., State Dept. of Education, Culture, and Tourism, etc.):
Name of Authorized State Agency Official (if different from above):
(Mr.)(Ms.)(Mrs.)(Other)
Title:
Mailing Address (if different from above):
City:
State:
Phone Number:
Fax Number:
E-Mail Address:
Name of Head of Library Development: (Mr.)(Ms.)(Mrs.)(Other):

Zip:

Title:
Mailing Address (if different from above):
City:
State:
Phone Number:
Fax Number:
E-Mail Address:
Name of LSTA Coordinator (Mr.)(Ms.)(Mrs.)(Other):

Zip:

Title:
Mailing Address (if different from above):
City:
Phone Number:
E-Mail Address:
Name of Fiscal Officer (Mr.)(Ms.)(Mrs.)(Other):

State:
Fax Number:

Zip:

Title:
Mailing Address (if different from above):
City:
State:
Zip:
Phone Number:
Fax Number:
E-Mail Address:
Names of People Authorized to sign Drawdowns. Please provide no more than two.