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3 lication for Federal <br /> Note: If available, please provide U.S. rtment of Education <br /> -� - application package on diskette Form Approved <br /> lucation Assistance and cnecifv the file farmnt OMB No. 1875 -0106 <br /> Exp. 06/30/2001 <br /> plicant Information <br /> lame and Address Organizational Unit <br /> egal Name: <br /> ■ddress: <br /> City State County ZIP Code + 4 <br /> Applicant's D -U -N -S Number: 1 I 1 I I I I 1 I 1 6. Is the applicant delinquent on any Federal debt? _Yes No <br /> (If "Yes," attach an explanation.) <br /> Applicant's T -I -N 1 I I-1 I I 1 ! I 1 ! Title: Fund for the Improvement of Education <br /> Catalog of Federal Domestic Assistance #: 84. 2 I 5 K 4 Earmarked Application <br /> Project Director: 7. Type of Applicant (Enter appropriate letter in the box.) <br /> Address: A - State H - Independent School District <br /> B - County 1 - Public College or University <br /> C - Municipal J - Private, Non - Profit College or University <br /> City State Zip code + 4 D - Township K - Indian Tribe <br /> Tel. #: ( ) - Fax 4: ( ) - E - Interstate L - Individual <br /> F - Intermunicipal M - Private, Profit - Making Organization <br /> E -Mail Address: G - Special District N - Other (Specify): <br /> 8. Novice Applicant Yes No <br /> pplication Information <br /> . Type of Submission: 12. Are any research activities involving human subjects planned at <br /> - PreApplication - Application any time during the proposed project period? _Yes No <br /> _Construction Construction a. If "Yes," Exemption(s) #: b. Assurance of Compliance #: <br /> Non - Construction Non - Construction <br /> OR <br /> I. Is application subject to review by Executive Order 12372 process? <br /> _ Yes (Date made available to the Executive Order 12372 c. IRB approval date: Full IRB or <br /> process for review): _/ l Expedited Review <br /> 13. Descriptive Title of Applicant's Project: <br /> No (If "No." check appropriate box below.) <br /> _ Program is not covered by E.O. 12372. <br /> — Program has not been selected by State for review. <br /> I. Proposed Project Dates: / / / / <br /> Start Date: End Date: <br /> ;stimated Funding Authorized Representative Information <br /> 15. To the best of my knowledge and belief, all data in this preapplication/application are true <br /> Ia. Federal S . 00 and correct. The document has been duly authorized by the governing body of the applicant <br /> . Applicant S . 00 and the applicant will comply with the attached assurances if the assistance is awarded. <br /> State S . 00 a. Typed Name of Authorized Representative <br /> . Local S . 00 <br /> Other S . 00 b. Title: <br /> Program Income S . 00 c. Tel. #: ( ) - Fax #: ( ) - <br /> d. E -Mail Address: <br /> . TOTAL S . 00 e. Signature of Authorized Representative <br /> ED 424 (rev 11/12/99) Date: / / <br />