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    Grant Application: Do Not Exceed Character Length Restrictions Indicated

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    myco sam
    This document appears to be a grant application form requesting information such as the title of the project, program director details, dates for support, costs, and certifications. Key sections include blocks for the project title, program director name and contact information, dates for the proposed support period, costs requested for the initial and total budget periods, applicant organization information, and signature of the official submitting the application. The level of detail requested is typical for a government grant application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Grant Application: Do Not Exceed Character Length Restrictions Indicated

    Uploaded by

    myco sam
    36 views1 page
    This document appears to be a grant application form requesting information such as the title of the project, program director details, dates for support, costs, and certifications. Key sections include blocks for the project title, program director name and contact information, dates for the proposed support period, costs requested for the initial and total budget periods, applicant organization information, and signature of the official submitting the application. The level of detail requested is typical for a government grant application.

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    Original Title

    EE

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    This document appears to be a grant application form requesting information such as the title of the project, program director details, dates for support, costs, and certifications. Key sections include blocks for the project title, program director name and contact information, dates for the proposed support period, costs requested for the initial and total budget periods, applicant organization information, and signature of the official submitting the application. The level of detail requested is typical for a government grant application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    36 views1 page

    Grant Application: Do Not Exceed Character Length Restrictions Indicated

    Uploaded by

    myco sam
    This document appears to be a grant application form requesting information such as the title of the project, program director details, dates for support, costs, and certifications. Key sections include blocks for the project title, program director name and contact information, dates for the proposed support period, costs requested for the initial and total budget periods, applicant organization information, and signature of the official submitting the application. The level of detail requested is typical for a government grant application.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Form Approved Through 03/31/2020 OMB No.

    0925-0001
    LEAVE BLANK—FOR PHS USE ONLY.
    Department of Health and Human Services
    Public Health Services Type Activity Number
    Review Group Formerly
    Grant Application
    Do not exceed character length restrictions indicated. Council/Board (Month, Year) Date Received

    1. TITLE OF PROJECT (Do not exceed 81 characters, including spaces and punctuation.)

    2. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT OR SOLICITATION NO YES


    (If “Yes,” state number and title)
    Number: Title:

    3. PROGRAM DIRECTOR/PRINCIPAL INVESTIGATOR


    3a. NAME (Last, first, middle) 3b. DEGREE(S) 3h. eRA Commons User Name

    3c. POSITION TITLE 3d. MAILING ADDRESS (Street, city, state, zip code)

    3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT

    3f. MAJOR SUBDIVISION

    3g. TELEPHONE AND FAX (Area code, number and extension) E-MAIL ADDRESS:
    TEL: FAX:
    4. HUMAN SUBJECTS RESEARCH 4a. Research Exempt If “Yes,” Exemption No.
    No Yes No Yes
    4b. Federal-Wide Assurance No. 4c. Clinical Trial 4d. NIH-defined Phase III Clinical Trial
    No Yes No Yes
    5. VERTEBRATE ANIMALS No Yes 5a. Animal Welfare Assurance No.
    6. DATES OF PROPOSED PERIOD OF 7. COSTS REQUESTED FOR INITIAL 8. COSTS REQUESTED FOR PROPOSED
    SUPPORT (month, day, year—MM/DD/YY) BUDGET PERIOD PERIOD OF SUPPORT
    From Through 7a. Direct Costs ($) 7b. Total Costs ($) 8a. Direct Costs ($) 8b. Total Costs ($)

    9. APPLICANT ORGANIZATION 10. TYPE OF ORGANIZATION


    Name Public: → Federal State Local
    Address Private: → Private Nonprofit

    For-profit: → General Small Business


    Woman-owned Socially and Economically Disadvantaged
    11. ENTITY IDENTIFICATION NUMBER

    DUNS NO. Cong. District

    12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE 13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
    Name Name

    Title Title

    Address Address

    Tel: FAX: Tel: FAX:

    E-Mail: E-Mail:
    14. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that SIGNATURE OF OFFICIAL NAMED IN 13. DATE
    the statements herein are true, complete and accurate to the best of my knowledge, and (In ink. “Per” signature not acceptable.)
    accept the obligation to comply with Public Health Services terms and conditions if a grant
    is awarded as a result of this application. I am aware that any false, fictitious, or fraudulent
    statements or claims may subject me to criminal, civil, or administrative penalties.
    PHS 398 (Rev. 01/18) Face Page Form Page 1

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