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<br />Attachment A <br /> <br />FY05 Homeland Security Grant Program <br />Application Cover Sheet for Cities with MMRS AUocations Only (Page 1 of 1) <br />Applicant (city) <br /> <br />-, <br /> <br />Authorized Agent Information: <br /> <br />Contact Information: <br /> <br />Name/Title <br /> <br />Mailing Address <br /> <br />City, State, Zip Code <br /> <br />Area Code/Office Telephone Number <br /> <br />E-Mail Address <br /> <br />Maximum MMRS Amount Authorized (from Appendix A) <br /> <br />$ <br /> <br />Total Amount Requested (from ISIP) <br /> <br />$ <br /> <br />Total Equipment Amount Requested for aU Programs <br /> <br />From ISIP <br /> <br />$ <br /> <br />From Eqnipment Worksheet <br /> <br />$ <br /> <br />Statement of Certification - City Authorized Agent <br /> <br />By signing below, I hereby certifY that I am the duly appointed Authorized Agent and have the authority to <br />apply for the FY 2005 Homeland Security Grant Program, and the City's application represents the needs for <br />the Metropolitan Medical Response System program. <br /> <br />Signature of Authorized Agent <br /> <br />Printed Name <br /> <br />Date <br /> <br />Title <br /> <br />For State use ONLY <br /> <br />Application reviewed/Grant award approved by: <br />Name <br /> <br />Date <br /> <br />Grant Performance Period: <br /> <br />OES ID # <br /> <br />Award # <br /> <br />FY05 Homeland Security Grant Program <br /> <br />Page 36 <br />