RFA #34347-39627 Perinatal Behavioral Health Workforce Development Project

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. Organization Information *This question is required.

Organization Name:
Organization's Primary Mailing Address:
Telephone Number:

5. Primary Contact Person *This question is required.

6. Secondary Contact Person *This question is required.

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

8. Service Location(s) and Address(es) where supervision services will be provided: *This question is required.

9. Counties served and designation (urban, rural, frontier): *This question is required.

10. Current number of licensed behavioral health professionals employed (by license type): *This question is required.

11. Current number of Pre-Licensed Clinicians employed (by license type pursued): *This question is required.

12. Number of Qualified Supervisors approved under Tennessee Board regulations (by license type): *This question is required.

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

14. Please upload your exceptions here: