Name of Nonpublic School:

Enter the name of the nonpublic school.

Street/P.O. Box:

Enter the street name and/or p.o. box number of the nonpublic school.

City:

Enter the name of the city in which the nonpublic school is located.

County:

Enter the name of the county in which the nonpublic school is located.

State & Zip:

Enter the state name and zip code of the nonpublic school.

Contact Person:

Enter the name of the contact person for this grant.

Title:

Enter the title of the contact person.

Phone:

Enter the phone number of the contact person.

Fax:

Enter the fax number of the contact person.

E-Mail:

Enter the e-mail address of the contact person.

LEA:

Enter the name of the LEA in which the nonpublic school is located.

Certifications:

Type the name and title of the authorized representative.  The authorized representative signs and dates the certifications.