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Applicant: <br />FY 2006 Emergency Management Performance Grant <br />Application for Assistance <br />Contact Information: <br />Authorized Agent Mailing Address Name /Title <br />City, State, Zip Code Area Code /Office Telephone Number <br />E -Mail Address <br />AllocatedAmount(from Appendix A) $ <br />Amount Requestedper Budget $ <br />Summary Worksheet <br />Application Checklist — The following items must be included with this grant application package: <br />Application for Assistance <br />Program Narrative <br />Budget Summary Worksheet <br />Certification and Signature of Authorized Agent <br />Governing Body Resolution (if required) <br />Grant Assurances (if required) <br />I am the duly appointed Authorized Agent and have the authority to applyfor this grant and submit this application on <br />behalf of the Operational Area. <br />Signature ofAuthorizedAgent <br />Printed Name <br />Date <br />Page 36 of 51 <br />