Attachment 6 – Application Coversheet
RFA#1209261035
Community-Based Breast Cancer Support and Wellness Services
Title of Project:
Applicant Organization:
Geographic region/counties to be served by this project:
Type of Organization:
(corporate status, e.g. not-for-profit corporation)
NAME AND ADDRESS OF APPLICANT ORGANIZATION/AGENCY
Project Director
Individual Authorized to Sign the Contract
Name:
Name:
Title:
Title:
Address:
Telephone:
Address:
Telephone:
E-mail Address:
E-mail Address:
Total State Funds Requested:
NYS Charity Registration Number:
Official Signature and Date:
_____________________________________
Official Signing for Application
Date
Organization:
NYS Vendor ID Number:
Name:
Title:
Address:
Telephone: