Application Name: Project Sponsor: Contact Information Applicant Sponsor Name: Name: Title: Title: Address: Address: City: City: County: County: Zip: Zip: Phone: Phone: Fax: Fax: Email: Email: Is project located within an MPO? Yes No (If yes, provide contact information below and include letter of project concurrence.) MPO: Contact Name: Address: Fax: City/Zip: Email: Project Cost: $0.00 Requested SRTS Amount: $0.00 ($200,000 max) Project Relations: Is this project contingent upon Yes No the completion of another SRTS project? If yes, provide name of project and details School Proximity: Is this project located within 2 Yes No miles of a primary or middle school (grades K-8)? Right-of-Way: Does this project require the Yes No purchase of additional Right-of-Way or Easement If yes, please explain approval?
Application Name: Project Sponsor: Contact Information Applicant Name: Sponsor Name: Title: Title: Address: Address: City: City: County: County: Zip: Zip: Phone: Phone: Fax: Fax: Email: Email: Is project located within an MPO? Yes No (If yes, provide contact information below and include letter of project concurrence.) MPO: Contact Name: Address: Fax: City/Zip: Email: Project Cost: $0.00 Requested SRTS Amount: $0.00 ($200,000 max) Project Relations: Is this project contingent upon the completion of another SRTS project? Yes No If yes, provide name of project and details School Proximity: Is this project located within 2 miles of a primary or middle school (grades K-8)? Yes No Right-of-Way: Does this project require the purchase of additional Right-of-Way or Easement approval? Yes No If yes, please explain
2019%20Infrastructure%20App.docx