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APPLICATION FOR OMB Approval No. 0348-0043 <br /> FEDERAL ASSISTANCE 2. DATE SUBMITTED Applicant Identifier <br /> a3 <br /> 1. TYPE OF SUBMISSION: 3. DATE RECEIVED BY STATE State Application Identifier <br /> A tion Preapplication <br /> Construction ~ Construction 4. DATE RECEIVED BY FEDERAL AGENCY Federal Identifier <br /> Non-Construction Non-Construction <br /> 5. APPLICANT INFORMATION <br /> Legal~+Name: Organizational Unit: <br /> i E~ .L ~ w ~ (iG. I.~O S ~ Q.f'Tt~'? <br /> Address (give city, county, State, and zip cale): Name and telephone number of person to a contacted on matters involvin <br /> ~~j g PGa~I this application(giVearea-code) X,.-t'-~ Cpre <br /> 7 <br /> 6. EMPLOYER IDENTIFICATION NUMBER (EIN): 7. TYPE OF APPLICANT: (enferappcopriate letter in box) <br /> 3 0 ~ b <br /> A. State H. Independent School Dist. <br /> 8. TYPE OF APPLICATION: B. County I. State Controlled Institution of Higher Learning <br /> ~w ? Continuation ? Revision C. Municipal J. Private University <br /> D. Township K. Indian Tribe <br /> If Revision, enter appropriate letter(s) in box(es) ~ ~ E. Interstate L. Individual <br /> F. tntermunicipal M. Profit Organization <br /> A. Increase Award B. Decrease Award C. Increase Duration G. Special District N. Other (Specify) <br /> D. Decrease Duration Other(specify): <br /> 9. NAME OF FEDEQRAL AGENCY: <br /> 10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: 11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT: cl <br /> t~ ~ / (5 - D A K I,c~i`l ~D cJ corm( tc~1~(atw,~ <br /> TITLE: W 1 (C~ Mot, a ,~.LS~ro rani o.~ <br /> 12. AREAS AFFECTED /BY PROJECT/(Gities, 6ouritie§; States etc:):• <br /> G 4-A~ l..-0~.r~, ~ o tf r.. <br /> 13. PROPOSED PROJECT 14. CONGRESSIONAL DISTRICTS OF: <br /> Start Date Ending Date a. Applicant b. Project <br /> 15. ESTIMATED FUNDING: 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE <br /> ORDER 12372 PROCESS? <br /> a. Federal $ 00 <br /> -t~J 7 ~ a. YES. THIS PREAPPLICATION/APPLICATION WAS MADE <br /> b. Applicant $ .°D AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 <br /> a 5~ o PROCESS FOR REVIEW ON: <br /> c. State $ 00 <br /> DATE <br /> d. Local $ °D <br /> b. No. ~'ROGRAM IS NOT COVERED BY E. O. 12372 <br /> e. Other $ .00 ? OR PROGRAM HAS NOT BEEN SELECTED BY STATE <br /> FOR REVIEW <br /> f. Program Income $ 00 <br /> 17. IS THE APPLICANT DELINQUENT ON ANY FEDERAL DEBT? <br /> g. TOTAL $ 00 <br /> S /~D ? Yes If "Yes; 'attach an explanation. <br /> i <br /> 18.'TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION ARE TRUE AND CORRECT, THE <br /> DOCUMENT HAS BEEN DULY AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL COMPLY WITH THE <br /> ATTACHED ASSURANCES IF THE ASSISTANCE IS AWARDED. <br /> a. Typ ame of Authorized Representative b. Title c. Teleph ber ^ ~ ~ 3.~ <br /> o ..~s M • I r Ci ~~dt <br /> <br /> ~5~ d. Si atur of Authorized pr sent e. Date ned <br /> r ition Usable ~ 5~ and Form 424 (Rev. 7-97) <br /> Authorized for Local Reproduction Prescribed by OMB Circular A-102 <br /> <br />