NEW MEXICOLSTA APPLICATION 2010-2011

I: GENERAL INFORMATION

  1. Project Title:
  1. Legal Name of Applicant (applicant will be responsible for all financial transactions):
  1. Mailing Address:
  1. Contact Person:

Telephone: Email:

  1. Project Funds (whole dollars only and must match budget)

Grant amount requested: / $
  1. County(ies) in which project will be implemented
  1. U. S. Congressional Districts: (provide number or numbers between 1 and 3):
  1. New Mexico Legislative House Districts: (provide number(s) between 1 and 70):
  1. New Mexico Legislative Senate Districts: (provide number(s) between 1 and 42):
  1. How many people do you expect will benefit from your project (please provide ONLY a number, no narrative needed)
  1. Identify the User Groups who will benefit from your project. (Check all that apply)

Adults / Children / Pre-school children
Young adults and teens / Senior populations / Statewide public
Urban population / Rural populations / People with special needs
Non/limited English-speaking persons

II. PROJECT DESCRIPTION & JUSTIFICATION

  1. Need and Outcomes:

Explain the need for this grant.How will the attending this conference impact the community that you serve?Describe one activity you will complete as part of this project and what the outcome of that activity will be for your library and community.

  1. Evaluation:

How will you evaluate this activity?What statistics will you keep? How will you know if the project achieved the desired outcomes?

III. INTERNET CERTIFICATION FOR APPLICANT PUBLIC LIBRAIRES

As duly authorized representative of the applicant library, I hereby certify that:
The requirements of Section 9134 (f)(1) of the Library Services and Technology Act do not
apply to the applicant library because no funds made available under the LSTA program will be used to purchase computers used to access the Internet or to pay for direct cost associated with accessing the Internet for a public library or public elementary school or secondary school library that does not receive discounted E-Rate services under the Communications Act of 1934, as amended.
Signature of Authorizing Official / Date

IV. CERTIFICATION OF LIBRARY PARTICIPATION

The library director and a representative of their governing body must sign a copy of this form.

Eligibility Requirements (please check all that apply):

My library is a public or developing library as defined by NMAC 4.5.2
My library is open to the public a minimum of 15 hours per week, two days per week
My library submitted an FY2009/2010 Annual Report

Certification (please initial all):

We have read the grant guidelines and the application for the proposed project.
We hereby assure and certify that we will comply with all regulations, policies, guidelines and requirements pertinent to the application and to the use of award funds including submitting
By our signatures, we certify my library’s financial and full commitment to participate in the proposed project as described in grant application including paying our matching portion of the grant.
We understand that all funds will be paid on a reimbursement basis.
We certify the application to be true and accurate to the best of my knowledge.
The applicant agrees to submit a final report,which will include a narrative, budget and certification by the final report deadline.
If thisapplication is approved, I certify that the project will begin promptly, and will be completed as described.

Library Director:

Print Name:
Date:
Signature:

V. Application Checklist: (all must be checked and included in the grant application)

Completed application with original signatures
Debarment, Suspension Certification Form
Budget Summary

The complete application with all attachments must be received at the State Library no later than 4:00 p.m. on March 11, 2011.

For this grant we will accept an electronic version on March 11, 2011, but the original with all original signatures must be received before the agreement is signed.

Mail or deliver one copy of your application to:

(electronic version)

Original with original signatures to:

Geraldine Hutchins

Federal Programs Coordinator

New MexicoState Library

1209 Camino Carlos Rey

Santa Fe, NM87509

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