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2. APPLICANT INFORMATION
4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
15. Is the applicant an*

    1. Organization
    2. Individual
17. Name of Project Director
18. Name of Authorized Representative

    (who signs the application and award contract)

20. Signature of Authorized Representative
21. Date
    Date
23. ABOUT THE PROJECT
25. Applicant Description*
27. Is this funding request for an emergency or crisis response, or a regular request?*

    1. Emergency or crisis response

    1. Regular request
29. Please provide details as to the exact nature of the emergency/crisis.
31. Describe what the funding is sought for, including details of the need for funds and what outcome is being sought with the use of funds.*
33. Upload any documents relating to the need for funds and outcome here.
35. Populations served/target population and geographic area served*
37. Upload any supporting documents here.
39. Data to support need for project
41. Upload any supporting documents here.
43. Proposed timeline
45. Upload any supporting documents here.
47. Details regarding funded activities

    Please list the desired outcomes and timeline for each activity.

49. Upload any supporting documents here.
51. Success: How will success be measured?
53. Sustainability: How will the project be sustained after the funding cycle?
55. Budget: Total amount requested*
57. Budget Documentation*

    Attach a breakdown of exactly how the requested funds will be used. 

59. If new, is the project evidence-based or based on promising practices?*

    1. Yes
    2. No
    3. The project is not new.
61. SUPPORTING DOCUMENTS
63. Resume and/or biography of project director
65. Budget itemization

    Please include a narrative of details regarding each expenditure.

67. Any other attachments that will provide a more complete picture of the funding requested
69. Letters of support from partner organizations (optional)
71. Materials demonstrating experience, organizational impact and/or commitment to addressing the drug overdose epidemic (optional)
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit Submit and Print

* indicates a required field