Address: City, State and Zip: Area Code / Phone No.: Fax No.: E-Mail Address: Legal Service Provider Comparable Database Name (if applicable): Contact: Last, First and Middle Names: Mr. Mrs. Ms. Other Title: Address: City, State and Zip: E-Mail Address: Area Code / Phone No.: Fax No.: FORM IV: LEGISLATIVE AND CONGRESSIONAL INFORMATION Provide the Legislative and Congressional information for the applicant and each activity location, (if different than applicant location), included in this application. To locate or verify the Legislative and Congressional information, click on the respective links below and enter the applicant office location zip code, the activity location site zip code(s) (i.e., zip code(s) where activities are performed), and any additional activity location site(s), as applicable. State Legislators: U.S. House of Representatives: District # First Name Last Name Applicant Office Location State Assembly Member State Senate Member U.S. of Representatives Activity Location(s) (if different from applicant – District # Name Last Name location) State Assembly Member State Senate Member U.S. of Representatives Activity Location(s) (if different from applicant – District # Name Last Name location)
Address: City, State and Zip: Area Code / Phone No.: Fax No.: E-Mail Address: Legal Service Provider Comparable Database Name (if applicable): Contact: Last, First and Middle Names: Mr. Mrs. Ms. Other Title: Address: City, State and Zip: Area Code / Phone No.: Fax No.: E-Mail Address: FORM IV: LEGISLATIVE AND CONGRESSIONAL INFORMATION Provide the Legislative and Congressional information for the applicant and each activity location, (if different than applicant location), included in this application. To locate or verify the Legislative and Congressional information, click on the respective links below and enter the applicant office location zip code, the activity location site zip code(s) (i.e., zip code(s) where activities are performed), and any additional activity location site(s), as applicable. State Legislators: U.S. House of Representatives: Applicant Office Location District # First Name Last Name State Assembly Member State Senate Member U.S. of Representatives Activity Location(s) – (if different from applicant location) District # Name Last Name State Assembly Member State Senate Member U.S. of Representatives Activity Location(s) – (if different from applicant location) District # Name Last Name
2017ApplicationfortheContinuumofCareAllocationAmended(DOC).docx