Grant Number ______________ [Crime Commission Use Only] NEBRASKA CRIME COMMISSION FY 2018 STATE JUVENILE SERVICES APPLICATION SECTION I: APPLICANT INFORMATION 1. Applicant Name: Name: Telephone: [ ] [Agency/Organization] Fax: [ ] The applicant must be the agency that will receive and disburse the grant funds. 2. Applicant Federal Employer ID #: [Must be 9 digits] 3. Address: [Include zip code + 4 digits] 4. Project Title: Name: Telephone: [ ] 5. Project Director: [Receives all grant correspondence] Title: Fax: [ ] Email: Address: [Include zip code + 4 digits] Name: Telephone: [ ] 6. Project Coordinator: [Cannot be the Project Director] Title: Fax: [ ] Email: Address: [Include zip code + 4 digits] 7. Fiscal Officer: Name: Telephone: [ ] [Cannot be the Project Director] Title: Fax: [ ] Email: Address: [Include zip code + 4 digits] 8. Authorized Official: Name: Telephone: [ ] [NOTE: The authorized official includes county Title: Fax: [ ] board chair, mayor, city administrator, state Email: agency director, chair or vice-chair of non-profit agency.] Address: [Include zip code + 4 digits]
Grant Number ______________ [Crime Commission Use Only] NEBRASKA CRIME COMMISSION FY 2018 STATE JUVENILE SERVICES APPLICATION SECTION I: APPLICANT INFORMATION 1. Applicant Name: [Agency/Organization] The applicant must be the agency that will receive and disburse the grant funds. Name: Telephone: [ ] Fax: [ ] 2. Applicant Federal Employer ID #: [Must be 9 digits] 3. Address: [Include zip code + 4 digits] 4. Project Title: 5. Project Director: [Receives all grant correspondence] Name: Title: Telephone: [ ] Fax: [ ] Email: Address: [Include zip code + 4 digits] 6. Project Coordinator: [Cannot be the Project Director] Name: Title: Telephone: [ ] Fax: [ ] Email: Address: [Include zip code + 4 digits] 7. Fiscal Officer: [Cannot be the Project Director] Name: Title: Telephone: [ ] Fax: [ ] Email: Address: [Include zip code + 4 digits] 8. Authorized Official: [NOTE: The authorized official includes county board chair, mayor, city administrator, state agency director, chair or vice-chair of non-profit agency.] Name: Title: Telephone: [ ] Fax: [ ] Email: Address: [Include zip code + 4 digits]
FY18-Juvenile-Services-Application.docx