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					                                                                 EFSP LOCAL BOARD
                                            City of Detroit and Wayne, Oakland, and Macomb Jurisdictions
                                                                       Phase 29


                                                                     COVER PAGE

           Check one. A separate application must be filled out for each jurisdiction in which you are seeking funding. Please remember that
           City of Detroit funding must be spent only on City of Detroit clients, Wayne funding on Wayne clients, etc., and you must be able
    1.     to document the spending.

                                City of Detroit
                                Wayne
                                Oakland
                                Macomb

           Please list all LRO numbers under which your agency has received funding in the past. Failure to list this may mean that your
    2.     agency will be evaluated as a "new" agency and may affect Phase 29 funding.

                 Jurisdiction        Agency
           ex.         484400                     000




    3.     Legal name of Agency

    4.     Program name

    5.     Mailing address

    6.     City                                                                                                    State               Zip
                                                                                                                   MI
    7.     Program site address

    8.     City                                                                                                    State               Zip
                                                                                                                   MI
    9.     Executive Director/CEO

   10.     Telephone

   11.     Email


Please choose your contact person carefully. Please be sure that the contact person's name, phone numbers, and email are accurate. Email
          will be used by both the Local Board and the National EFSP Board for almost all communication, including deadlines.

   12.     Contact person

   13.     Telephone                                                                                               Fax

   14.     Alternate phone (cell or other)


LROs that are not able to check email 2 or 3 times each week and use it to communicate may have difficulty in meeting the requirements of a
                                                         successful EFSP partner.

   15.     Contact person email - MANDATORY

           What year did program begin
   16.     delivering services?

           What year did agency begin
   17.     delivering services?

To the best of my knowledge and belief, the data in this proposal is true and correct and the governing body of the applicant has duly authorized the
enclosed documents.
 I understand that incomplete applications or applications submitted after the deadline will not be accepted or reviewed.

By signing below, the undersigned acknowledges having read and understood the program guideliness and will be able to fully comply with the
provisions of these guidelines as well as any and all additional applicable federal, state, and local requirements.

Executive Director's signature                                                                                     Date

Board chair's signature                                                                                            Date

				
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posted:10/26/2011
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