CSB Programs

1. Applicant & Project Information
Project Name:		Amount of funding requested:
Brief Project Description:
Name of Lead Organization (project sponsor):
Mailing Address:
Contact Person:
Telephone:	Fax:		E-mail
2. Authorization
Acting as a duly authorized representative, I hereby affirm that the governing body of the below named organization has reviewed and accepts all the conditions described in the CSB Master Provider Agreement (OS-00) and the Shelter Program Agreement (OS-00-1), and the organization wishes to be considered for funding by the Community Shelter Board.
Executive Director (or equivalent):				Date:
Authorized Signature:
Name/Title:
Program Director (or equivalent):				Date:
Authorized Signature:
Name/Title:
Finance Director (or equivalent):				Date:
Authorized Signature:
Name/Title: