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<br />ARK- TEX COUNCIL OF GOVERNMENTS <br />ECONOMIC DEVELOPMENT INFRASTRUCTURE <br /> GRANT PROGRAM <br />1. IDENTIFICATION OF APPUCANT (identify lead applicant, if joint application) <br />Name: Lead Applicant: <br />Street/P.O. Box: City: Zip: <br />Contact Person: <br />(rnle, Phone Number, Address) <br />2. LOCAL EMPLOYMENT 3. EMPLOYMENT IMPACT <br /> #Non- <br /> #Minority Minority % of jobs to low/mod. income <br />Total Employment: Jobs Created: <br />Pop. of Jurisdiction/ Jobs Retained: <br />Jurisdictions: TOTALJOBS: <br />4. ESTIMATED COSTS (min. 5% cash injection of total proj. costs required of principals) <br />ATCOG EDIGP: $ *Other: Applicant <br />*Other: $ Private <br /> Other State <br />Total: $ or Federal <br />5. COST PER JOB <br />Total EDIGP requested divided by total jobs = cost/job <br />6. TITLE AND BRIEF SUMMARY OF PROJECT: <br />7. AUTHORIZED LOCAL GOVERNMENT OFFICIAL (MAYOR OR COUNTY JUDGE) <br />Signature Print Name and Title Date <br />Note: Mail original and one Ark- Tex Council of Governments <br />copy to: Director of Program Operations <br /> P.O. Box 5307 <br /> Texarkana, Texas 75505 <br /> <br />1<1 <br />