Form 4040-0010 Key Contacts

OMB Approval No.:4040-0010
Expiration Date: mm/dd/yyyy

Key Contacts Form

* Applicant Organization Name:

I

Enter the individual's role on the project (e.g., project manager. fiscal contact).
• Contact 1 Project Role: I

Prefix:

• First Name:

I

I

I

I

I

Middle Name:

• Last Name:

I

I

Suffix:
Title:

Orjlanizational Affiliation:

I

I

• Street1:
Street2:

• City:

County:

• State:

Province:

• Country:

• Zip / Postal Code:

• Telephone Number:
Fax:

• Email:I

I
I

l

I

I

I

I

I

USl\: UNTTc;O STATES

I

I

I

I

. -"-·
Next Person

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 4040-0010. The time required to complete this information collection is estimated to average 1 hour per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200
Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer