RFA #34347-04226 DPP Expansion Application

Applicant Information

1. Legal name of applicant as it appears on its corporate charter: *This question is required.

2. Federal Tax ID Number: *This question is required.

3. Is your organization a registered vendor with the State? *This question is required.

4. Edison Vendor Number: *This question is required.

4. Organization's DUNS number: *This question is required. *To get a DUNS number: Claim Your Free D-U-N-S Number - Dun & Bradstreet

5. Organization’s SAM Registration/Number: *This question is required. *To register with SAM: Home | SAM.gov

6. Organization contact information: *This question is required.

Organization's Primary Mailing Address:
Phone Number:

7. Primary Contact Person: *This question is required.

8. Secondary Contact Person:

9. If awarded a grant, who will be the authorized signor of the resulting contract?
*This question is required.

10. County(ies) where services will be provided: *This question is required.

11. Priority population(s)that will be served: *This question is required.

12. Anticipated number of participants: *This question is required.

13. Please check ONE of the following as it applies to this application.
*This question is required.

14. Please attach documentation of requested changes/exceptions. *This question is required.

14. Please upload your signed Competitive Requirements form: *This question is required.