OMB Number: 4040-0004

Expiration Date: 12/31/2019

* 1. Type of Submission: * 2. Type of Application:

* 3. Date Received: 4. Applicant Identifier:

5a. Federal Entity Identifier: 5b. Federal Award Identifier:

6. Date Received by State: 7. State Application Identifier:

* a. Legal Name:

* b. Employer/Taxpayer Identification Number (EIN/TIN): * c. Organizational DUNS:

* Street1:

Street2:

* City:

County/Parish:

* State:

Province:

* Country:

* Zip / Postal Code:

Department Name: Division Name:

Prefix: * First Name:

Middle Name:

* Last Name:

Suffix:

Title:

Organizational Affiliation:

* Telephone Number: Fax Number:

* Email:

* If Revision, select appropriate letter(s):

* Other (Specify):

State Use Only:

8. APPLICANT INFORMATION:

d. Address:

e. Organizational Unit:

f. Name and contact information of person to be contacted on matters involving this application:

Application for Federal Assistance SF-424

Preapplication

Application

Changed/Corrected Application

New

Continuation

Revision

submission date

COMPANY NAME

XX-XXXXXX XXXXXXXXX

COMPANY STREET ADDRESS

USA: UNITED STATES

COMPANY REPRESENTATIVE FNAME

COMPANY REPRESENTATIVE LNAME

CEO, PRESIDENT, FOUNDER, ETC.

Not all fields are required and may be left blank. Some fields are auto-filled by Grants.gov

COMPANY CITY

COMPANY STATE

5 DIGIT ZIPCODE

PHONE#

EMAIL ADDRESS
* 9. Type of Applicant 1: Select Applicant Type:

Type of Applicant 2: Select Applicant Type:

Type of Applicant 3: Select Applicant Type:

* Other (specify):

* 10. Name of Federal Agency:

11. Catalog of Federal Domestic Assistance Number:

CFDA Title:

* 12. Funding Opportunity Number:

* Title:

13. Competition Identification Number:

Title:

14. Areas Affected by Project (Cities, Counties, States, etc.):

* 15. Descriptive Title of Applicant's Project:

Attach supporting documents as specified in agency instructions.

Application for Federal Assistance SF-424

R: Small Business

National Institute of Standards and Technology

11.620

Science, Technology, Business and/or Education Outreach

YEAR-NIST-SBIR-01 (NOFO#)

Small Business Innovation Research (SBIR) Program Phase I

The title of your proposal

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* a. Federal

* b. Applicant

* c. State

* d. Local

* e. Other

* f. Program Income

* g. TOTAL

.

Prefix: * First Name:

Middle Name:

* Last Name:

Suffix:

* Title:

* Telephone Number:

* Email:

Fax Number:

* Signature of Authorized Representative: * Date Signed:

18. Estimated Funding ($):

21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements

herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to

comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may

subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)

** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency 

specific instructions.

Authorized Representative:

Application for Federal Assistance SF-424

* a. Applicant

Attach an additional list of Program/Project Congressional Districts if needed.

* b. Program/Project

* a. Start Date: * b. End Date:

16. Congressional Districts Of:

17. Proposed Project:

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9/1/YEAR 03/01/YEAR

100,000.00

0.00

0.00

0.00

0.00

0.00

100,000.00

a. This application was made available to the State under the Executive Order 12372 Process for review on

b. Program is subject to E.O. 12372 but has not been selected by the State for review.

c. Program is not covered by E.O. 12372.

Yes No

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** I AGREE

FName

LName

CEO, President, etc.

Full Name

* 20. Is the Applicant Delinquent On Any Federal Debt? (If "Yes," provide explanation in attachment.)

* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?

If "Yes", provide explanation and attach

**State abbreviation plus district number (e.g. "TX-002"). To find your number, visit House.gov webpage & enter your organization’s zip code under the Find 

Your Representative heading in the top-right corner. The name of your representative and his or her district number will appear in the results. If a district is 

described as “at large”, then the congressional district number should be entered “001”. 16a and 16b should have the same code.

**

PHONE#

EMAIL ADDRESS

September 1 in Year of application 6 month duration