Alexandria Fund for Human Services FY2016

APPLICATION COVER SHEET

NOTE: Questions with * are required.

Identify the specific Alexandria Fund for Human Services City Outcome to which this proposal applies. Check one:

Section of the Fund, "New" or "Established," in which applying for funding (please check one):

For a joint application with two or more applicants, select the option below to indicate that the proposal is a joint application; and identify the lead organization and the partnering organizations.

Identify the Lead Organization and Partnering Organizations:

Applicant Information

Organization Name

Program Title

Address

Fax No.

Executive Director's Name

Telephone No.

E-Mail Address

Fax No.

Contact Person's Name

Telephone No

Email Address This question requires a valid email address.

Fax No.

Organization's Total Projected Budget Income for FY 2016 ( exclude in-kind contributions ): This question requires a valid number format.

Grant Amount Requested: This question requires a valid number format.

Geographic Area(s) Being Served: This question requires a valid number format.

Populations(s) Priority(ies) Being Addressed: This question requires a valid number format.

Grant Priority(ies) Being Addressed: This question requires a valid number format.

Briefly Describe the Program or Services to be Provided:

By submitting this application, the applicant offers and agrees if the proposal is accepted, to furnish items or services for which prices are quoted, subject to final negotiation and acceptance by the City of Alexandria and subsequent contract award.

Submission Deadline for Fiscal Year 2016 : All proposals must be received no later than 11:59 p.m., March 3, 2015

I certify to the best of my knowledge, information regarding this proposal reflects accurate data regarding need and estimates of planned/delivered services. The proposal was considered and approved for submission by the agency Board of Directors on (date).

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Alexandria Fund for Human Services FY2016

Application Cover Sheet