State Use Only Grant # ______________ NEBRASKA CRIME COMMISSION FY 2018 STOP Violence Against Women Act GRANT APPLICATION *Attach Proof of Non-profit Status 1. Applicant Name: Legal Name: Telephone ( ) (Agency/Organization) The applicant must be the agency that will Fax ( ) receive and disburse the grant funds. 2. Applicant Federal Employer ID #: (must be 9 digits) 3. Applicant DUNS #: 4. Applicant Address: (physical address) (Include zip code + 4 digits) 5. Project Title: 6. Project Point of Contact: PPOC Name: (Main contact. Responsible for all Title: correspondence regarding grant award and project.) Email: Telephone( ) Fax ( ) Address: (Include zip code + 4 digits) 7. Project Coordinator: Name: (Individual who serves as the secondary Title: contact for the project.) Telephone( ) Fax ( ) Address: (Include zip code + 4 digits) 8. Fiscal Point of Contact: FPOC Name: Title: (Responsible for fiscal oversight and fiscal reports. Cannot be same as the PPOC) Email: Telephone( ) Fax ( ) Address: (Include zip code + 4 digits) 9. Authorized Official: Name: (NOTE: The authorized official is the Title: Mayor, Chair of County Board or City Email: Telephone( ) Council or the Board Chair of a Private Fax ( ) Non-profit Agency.) Address: (Include zip code + 4 digits) 10. Previous 5-Years Commission Funding for This Project: Grant #: Amount: #: Amount:
State Use Only Grant # ______________ NEBRASKA CRIME COMMISSION FY 2018 STOP Violence Against Women Act GRANT APPLICATION *Attach Proof of Non-profit Status 1. Applicant Name: (Agency/Organization) The applicant must be the agency that will receive and disburse the grant funds. Legal Name: Telephone ( ) Fax ( ) 2. Applicant Federal Employer ID #: (must be 9 digits) 3. Applicant DUNS #: 4. Applicant Address: (physical address) (Include zip code + 4 digits) 5. Project Title: 6. Project Point of Contact: PPOC (Main contact. Responsible for all correspondence regarding grant award and project.) Name: Title: Email: Telephone( ) Fax ( ) Address: (Include zip code + 4 digits) 7. Project Coordinator: (Individual who serves as the secondary contact for the project.) Name: Title: Telephone( ) Fax ( ) Address: (Include zip code + 4 digits) 8. Fiscal Point of Contact: FPOC (Responsible for fiscal oversight and fiscal reports. Cannot be same as the PPOC) Name: Title: Email: Telephone( ) Fax ( ) Address: (Include zip code + 4 digits) 9. Authorized Official: (NOTE: The authorized official is the Mayor, Chair of County Board or City Council or the Board Chair of a Private Non-profit Agency.) Name: Title: Email: Telephone( ) Fax ( ) Address: (Include zip code + 4 digits) 10. Previous 5-Years Commission Funding for This Project: Grant #: Amount: #: Amount:
2018%20STOP%20Application_0.docx