2011 Request For Proposal Cover Sheet Template

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STATE OF CONNECTICUT, Department of Public Health RFP # 2011-0917; Tobacco Use Cessation Services
APPLICATION FORMS
REQUEST FOR PROPOSAL COVER SHEET
TOBACCO USE PREVENTION AND CONTROL PROGRAM
RFP # 2011-0917
TOBACCO USE CESSATION TREATMENT SERVICES FOR CONNECTICUT RESIDENTS
A. Applicant Information
___________________________________________________________________________________________________
Legal Name
___________________________________________________________________________________________________
Address
___________________________________________________________________________________________________
City/Town
State
Zip Code
___________________________________________________________________________________________________
Telephone No.
FAX No.
E-Mail Address
Contact Person: ___________________________________________ Title: ____________________________________
Telephone No: ______________________________________________________________________________________
TOTAL PROGRAM COST:
$__________________
Number of Patients Counseled: Individual Sessions;
Number of Patients Counseled, other Individual
Initial Intensive Session
Sessions:
Average Cost per Initial Intensive Counseling
Average Cost per other Individual Session
Session
Number of Group Sessions:
Average Cost per Group Session:
I certify that to the best of my knowledge and belief, the information contained in this application is true and correct. The
application has been duly authorized by the governing body of the applicant, the applicant has the legal authority to apply for
this funding, the applicant will comply with applicable state and federal laws and regulations, and that I am a duly authorized
signatory for the applicant.
___________________________________________________________________________________________________
Signature of Authorizing Official:
Date
Typed Name and
Title
--------------------------------------------------------------------------------------------------------------------------------------------
The applicant agency is the agency or organization, which is legally and financially responsible and accountable for the use
and disposition of any awarded funds. Please provide the following information:
Full legal name of the organization or corporation as it appears on the corporate seal and as registered with the Secretary of State
Mailing address; Main telephone number; Fax number, if any
Principal contact person for the application (person responsible for developing application)
Total program cost
The funding application and all required submittals must include the signature of an officer of the applicant agency who has
the legal authority to bind the organization. The signature, typed name and position of the authorized official of the applicant
agency must be included as well as the date on which the application is signed.
RFP # 2011-0917 APPLICATION FORMS
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