Magnet Schools Assistance Program Grant Application FY 2017 CLOSING DATE 04/11/2017 U.S. Department of Education Office of Innovation and Improvement Washington, DC 20202-5970 CFDA Number: 84.165A Form Approved OMB No. 1855-0011 Expiration Date: 08-31-2019
audit disallowances, loans and taxes. If yes, include an explanation in an attachment. e. Organizational Unit: Enter the name of the primary organizational unit, department or division that will undertake the assistance activity. 21. Authorized Representative: To be signed and dated by the authorized representative of the applicant organization. Enter the first and last name (Required); prefix, middle name, suffix. Enter title, telephone number, email (Required); and fax number. A copy of the governing body’s authorization for you to sign this application as the official representative must be on file in the applicant’s office. (Certain federal agencies may require that this authorization be submitted as part of the application.) f. Name and contact information of person to be contacted on matters involving this application: Enter the first and last name (Required); prefix, middle name, suffix, title. Enter organizational affiliation if affiliated with an organization other than that in 7.a. Telephone number and email (Required); fax number. 9. Type of Applicant: (Required) Select up to three applicant type(s) in accordance with agency instructions. A. State Government B. County Government C. City or Township Government D. Special District Government E. Regional Organization F. U.S. Territory or Possession G. Independent School District H. Public/State Controlled Institution of Higher Education I. Indian/Native American Tribal Government (Federally Recognized) J. Indian/Native American Tribal Government than Federally Recognized) K. Indian/Native American Tribally Designated Organization L. Public/Indian Housing Authority M. Nonprofit N. Private Institution of Higher Education O. Individual P. For-Profit Organization than Small Business) Q. Business R. Institution S. Historically Black Colleges and Universities (HBCUs) T. Tribally Controlled Colleges and Universities (TCCUs) U. Alaska Native and Native Hawaiian Serving Institutions V. Non-US Entity W. Other (specify)
Yes Provide Exemption(s) # (s): ⁪ 1 ⁪ 2 ⁪ 3 ⁪ 4 ⁪ 5 ⁪ 6 No Provide Assurance #(s), if available: c. If applicable, please attach your “Exempt Research” or “Nonexempt Research” narrative to this form as indicated in the definitions page in the attached instructions.
Survey Ensuring Equal Opportunity for Applicants 1. Has the applicant ever received a grant or contract from the Federal government? Yes No 2. Is the applicant a faith-based organization? Yes No 3. Is the applicant a secular organization? Yes No 4. Does the applicant have 501(c)(3) status? Yes No 5. Is the applicant a local affiliate of a national organization? Yes No 6. How many full-time equivalent employees does the applicant have? (Check only one box). 3 or Fewer 15-50 4-5 51-100 6-14 over 100 7. What is the size of the applicant’s annual budget? (Check only one box.) Less Than $150,000 $150,000 - $299,999 $300,000 - $499,999 $500,000 - $999,999 $1,000,000 - $4,999,999 $5,000,000 or more