Children S Board of Hillsborough County

Children’s Board of Hillsborough County

PRO 2018 – 07 Request for Applications

(Level 2) Capacity Building Uniting Grant

ATTACHMENT #1 - Application Cover Sheet

“ApplicantOrganization Legal Name” must match agency name listed on the Florida Department of State Division of Corporation website:
1. Applicant Organization Legal Name:
2. Organization Address:
3. City: / 4. State: / 5. Zip Code:
6. Organization Phone Number: / 7. Organization Website:
8. Organization Type:______Not for Profit (Incorporation date: ____/____/______)
______Government
______Other (Please specify):
9. IRS Determination: ______501c3 ______Other (Please specify):
10. Registered Florida Charitable Organization:______Yes ______No
11. Current Children’s Board Funded Provider: ______Yes ______No

Contact Information:

12. CEO/ Executive Director Name:
13. CEO/ Executive Director Phone Number: / 14. CEO/ Executive Director Email:
Is the CEO/ Executive Director the main contact for the proposed program? ______Yes _____ No
If no, please complete the following information about the Applicant Organization’s Contact Person:
15. Organization Contact Person Name:
16. Organization Contact Person Phone Number: / 17. Organization Contact Person Email:

Hillsborough County BOCC District:

Refer to the Hillsborough County Website: and click on Find My Elected Official to determine in which Board of County Commission district the Applicant Organization resides.
18. Commission District:
_____ 1 _____ 2 _____ 3 _____4 (District 5,6,&7 are at large seats)
19. If Applicant Organization is located within the city limit, please indicate:
_____ City of Tampa _____ City of Temple Terrace _____ City of Plant City _____ Not Applicable

Program Information:

20. Applicant Program Name:
21. Applicant Service Area: ______County-Wide
_____ Geographic Region(s)
If geographic region(s), please specify:
22. Applicant Program Deliverable(s)(check all that apply):
______
______
______
______
23. Applicant Program Summary: 50 words or less to articulate program services to the general public.
24. Applicant Total Budget = $
25. Amount of Request from CBHC = $
26. Number of unduplicated participants to be trained:
27. How did you hear about thisRequest for Applications?
I do hereby certify to the above statements and that all facts, figures, and representations made in this proposal and supporting documents are true and correct. Furthermore, I certify that I have been duly authorized to act as the authorized representative of the Applicant Organization in connection with filling out this proposal, and have obtained any necessary authorization from the proposer’s governing body for the submission of this proposal. I acknowledge that this proposal and all additional documents submitted become the property of the Children’s Board and will become public record subject to the provisions of Chapter 119, Florida Statutes.
______
Signature of Authorized Official Signature of Applicant Organization’s Board Chair
______
(Printed Name) (Printed Name)
______/____/______
(Title) (Date)
____/____/______
(Date)