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<br />CDSG 2007-2008 <br />APPUCATlON FORM <br /> <br />J. <br />A <br /> <br />~=FO~TION \) . <br />Legal Cllla,.;. allanal Name.. So ~ti-l. c:::A1- r <e~ NMl ~ ""'~ ~ <br /> <br />Is organization affiliated with a religious institution? 0 y~O <br /> <br />Name of program~ .:..- / /..... _ _ <br />"~Y'VN'I7~ ~ <br /> <br />1. Business Office Address: .........,...,.", ~. 'V' JI*::::- ~ "', 0 I <br />l:z..e Wt!!!fi?;;;.,- <:.J V I C- ~l I.. ~ t::S J <;:-A- [-., <br /> <br />2. Location(s) ~e ~ogram services are to be provided: <br />SA--M <br /> <br />Contact Information <br />AI/Information will be delivered to this individual to distribute appropriately within your <br />organization__. / ~ - 0 . <br />Name: ItMfJ7tty Rl/~it Title: M.. Vl~ f~(fJ~ <br /> <br />Daytime Telephone: ~2-207 a7 "50 FAX: · <br /> <br />E-Mail Address: -1-1 m Y' l.J~ ~ @'l> V' V\ c::::t\--f'e4J4--t...t . ~ <br />,- , <br />Official authorized to sign agreement (If awarded this name Will be used for your contrjl9t) ... <br />Name~H~)::>.~A- Title: Hr<-S-, V\~ LYe:s;-ID~ <br /> <br />Non-profit Incorporation Information: /1) ^ ~ ., ~~ -D .. I ~ <br />Federal Tax ID#: State:~_ r::::Jl.J"--fY I ~ <br />Attach a copiof agency's IRS non-proftt designation letter as Attachment #1, <br /> <br />Permitted Land Use: Attach, as Attachment #2, evidence that your organization's use of <br />properties, listed above in 01 and/or D2, are permitted by the CIty's zoning code, Appropriate <br />evidence includes copy of 1) Certificate of Occupancy, 2) Business Ucense, or 3) other equivalent <br />proof of approval to conduct proposed activity at the designated site. <br /> <br />Licenses: If applicable attach copies of your agency's licenses{s)lcertificate(s) needed to operate <br />the proposed program as Attachment #3. If no licenses/certificates are required to perform this <br />service include a letter indicating this fact as attachment #3 <br /> <br />Amount of funding requested for FY 07-08: $"81, S-v1> (Automatic) <br /> <br />B, <br />c. <br /> <br />o. <br /> <br />E, <br /> <br />F. <br /> <br />G, <br /> <br />H. <br /> <br />I. <br /> <br />J, <br />K <br /> <br /> <br />2 <br />