Form 2020 - Con Determination Form (Page 2 of 3) in pdf

Form 2020 - Con Determination Form Page 2

Page 2 of 3

Contact Person’s Mailing Address, if PO

Box, include a street mailing address for

Certified Mail

Contact Person’s Telephone Number

Contact Person’s Fax Number

Contact Person’s e-mail Address

SECTION II. GENERAL PROPOSAL INFORMATION

Proposal/Project Title:: ____________________________________________

Estimated Total Project Cost: $__________________________

Location of proposal, identifying Street Address, Town and Zip Code:

__________________________________________________________________

List each town this project is intended to serve:

__________________________________________________________________

Estimated starting date for the project: ___________________________________

SECTION IV. PROPOSAL DESCRIPTION

Please provide a description of the proposed project, highlighting each of its important aspects,

on at least one, but not more than two separate 8.5” X 11” sheets of paper. At a minimum

each of the following elements need to be addressed, if applicable:

1. If applicable, identify the types of services currently provided and provide a copy of each

Department of Public Health license held by the Petitioner.

2. Identify the types of services that are being proposed and what DPH licensure categories

will be sought, if applicable.

3. Identify the current population served and the target population to be served.

Form 2020

Revised 08/11

Form 2020 - Con Determination Form Page 2