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<br /> ~ <br /> - <br /> GENERAL SERVICES COMMISSION <br /> INTER-GOVERNMENTAL PROGRAMS <br /> FEDERAL SURPLUS PROPERTY PROGRAM <br /> APPLICATION FOR ELIGIBILITY <br /> To Receive Federal Surplus Property (41 CFR 101-44,207) <br />I I. LEGAL NAME & MAILING ADDRESS OF APPLICANT ORGANIZATION: <br /> 'lame of OrganlzaClon i=eaeral Tax ID# <br /> Streee AddresS/Location <br /> ,\1alling Address (P. 0. Box #. Slreet C;ty & Slate, (9 Dlgl/ Zip Coae) <br /> :ounty -:-eleonone 11 <br /> 'I. APPLICANT STATIJS (CHECK ONE): <br /> D Public Agency including Public SchOOlS (evidence must be provided I Fiscal Year Ending <br /> Date: <br />I D Nonprofit. tax-exempt Organization <br />III. TYPE OR PURPOSE OF ORGANIZATION: <br /> D Slale D COllecJtOf UnIY,",slty D Ch,ld Car. CantIN' D Tralnlnq Center D '.~ec1lCalln.tlIVtIOn <br /> D County D 5econoarv SchOOl D SChOOllQf Hen(llcaopftO 0 RadlClfTV StatIOn D ";OSO'''I <br /> D Citv 0 Elementary School 0 School lor AetaroeG 0 L......, 0 HeallhCem.. <br />I D Sch0Q40istnc:1 D PrncnOOI D '-4uMum 0 Shell.eo Worltsnoo Tralnlnq Proqrams <br /> 0 Program for Old., InclMCIuala 0 P1'OY1der ol.........nc.IO HomeleSS InCllYIduata 0 ::,I"IIC <br /> 0 Oth.,IIDeClfyl <br /> I rv. SOURCES OF FUNDING (Attach Supporting Documentation); <br /> 0 Tu SUDOQt1eo 0 Grant 0 Con"""",," o OtherrSptICltv) <br /> V. HAS THE ORGANIZATION BEEN APPROVED, ACCREDITED, OR <br /> LICENSED? (COPY REQUIRED) BY WHAT AUTHORITY? <br /> r:ff' NON-PROFIT ORGANIZATIONS INCLUDING VOLUNTEER FIRE DEPARTMENTS COMPLETE PARTS VI AND VI/, <br /> VI. PROVIDE A WRITTEN DESCRIPTION OF PROGRAM OR SERVICES <br /> OFFERED, INCLUDING A DESCRIPTION OF FACILITIES OPERATED (REQUIRED) <br /> VII. HAS THE ORGANIZATION BEEN DETERMINED TO BE TAX EXEMPT UNDER SECTION <br /> 501 OF THE INTERNAL REVENUE CODE OF 1954: (COPY REQUIRED) <br /> VIII. <br /> Date Printea Name of Aulhoflzea Official Signature of AuthonzeC1 Official <br /> FOR STATE AGENCY USE ONLY <br /> The applicant has been aelerrnlned 0 eligible D ineligible <br /> a. 0 a public agency, 0 nonprofit education, 0 nonprofit heaJth <br /> Eligibility expIres Account # <br /> Date EXHBI A Director <br /> ~ <br /> <br />MAIL COMPLETED FORMS TO: <br /> <br />II <br /> <br />II rz::neaAI ellon...~ n",...ru-~ ",n,......" <br />