State Programs - Information Update form

D ate submitted __________
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GRANTS TO STAT
TES
INFORMA
ATION UPDATE
State Library
y Administrative Agency (SLAA)
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Name:
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Mailing Addreess:
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City, State, Ziip:
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DUNS Numbeer:
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EIN:
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Parent Organization, if appliicable
(e.g., Dept. off Administratio
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on): _________
Chief Officerr of SLAA
Name:
______
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Title:
______
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Phone:
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Fax:
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Email:
______
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Is the Chief Officer
O
also the Authorized Ceertifying Officiial?
Yes
No (if no, pleease designate below)
Authorized Certifying
C
Offficial (if different from Chieef Officer)
Name:
______
_____________
_________________________________________________________
____________
Title:
______
_____________
_________________________________________________________
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Mailing Addreess (if differen
__________________________________________________________
nt from above): ___________
City, State, Ziip (if different from above): ____________
_________________________________________________________
______
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Phone:
__________________________________________________________
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Fax:
__________________________________________________________
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Email:
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LSTA Coordinator
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Name:
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Title:
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Mailing Addreess (if differen
__________________________________________________________
nt from above): ___________
City, State, Ziip (if different from above): ____________
_________________________________________________________
______
Phone:
____________
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______
Fax:
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__________________________________________________________
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Email:
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Head of Library Development
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Name:
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Title:
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Mailing Addreess (if differen
__________________________________________________________
nt from above): ___________
City, State, Ziip (if different from above): ____________
_________________________________________________________
______
Phone:
____________
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______
Fax:
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__________________________________________________________
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Email:
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Fiscal Officerr
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Name:
_____________
_________________________________________________________
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______
Title:
_____________
_________________________________________________________
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Mailing Addreess (if differen
__________________________________________________________
nt from above): ___________
City, State, Ziip (if different from above): ____________
_________________________________________________________
______
Phone:
____________
__________________________________________________________
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______
Fax:
____________
__________________________________________________________
____________
Email:
______
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_________________________________________________________
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