Amount Requested: $_______________ In what areas of Broward County are services to be provided? (North, South, Central, or County-wide?) Or targeting zip codes with high rates of fetal/infant mortality and prematurity concentrated in several of the county’s zip codes. List of Zip Codes to be Served: ________________________________________________________________ Proposal Contact Person: _______________________________________ Phone Number: _______________________________________ _______________________________________ Name of Partner(s) or Sub-Contractors *if applicable ________________________________________________________________ APPLICATION FOR FUNDS Part I Section A. Applicant Agency Information: Cover Sheet Agency Legal Name must match Agency name listed on the Florida Department of State Division of Corporation website: Agency Legal Name: Main Administrative Address: City & State: Zip Code: Telephone Number: Fax Number: CEO/Executive Officer: Email: Office Phone Number: Financial Officer: Email: Office Phone Number: Agency Contact Person: Office Number:
Amount Requested: $_______________ In what areas of Broward County are services to be provided? (North, South, Central, or County-wide?) Or targeting zip codes with high rates of fetal/infant mortality and prematurity concentrated in several of the county’s zip codes. List of Zip Codes to be Served: ________________________________________________________________ Proposal Contact Person: _______________________________________ Phone Number: _______________________________________ _______________________________________ Name of Partner(s) or Sub-Contractors *if applicable ________________________________________________________________ APPLICATION FOR FUNDS Part I Section A. Applicant Agency Information: Cover Sheet Agency Legal Name must match Agency name listed on the Florida Department of State Division of Corporation website: Agency Legal Name: Main Administrative Address: City & State: Zip Code: Telephone Number: Fax Number: CEO/Executive Officer: Email: Office Phone Number: Financial Officer: Email: Office Phone Number: Agency Contact Person: Office Number:
ITN-Attachment-F-ITN-Application-1.docx