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Application Submittal Checklist 11/13/2017 11:44:58 AM Page 6 of 20 <br /> <br /> <br /> <br /> <br />Agency ______________________________ <br /> <br />Program(s) ______________________________ <br /> Section Subsection <br />1. Cover Page <br /> <br />a. Applicant Contact Information <br />b. Funding Requests <br />c. Signed Application Cover Page <br />d. Signed Disclosure of Conflicts of Interest and Clause <br /> <br /> <br /> <br /> <br /> <br />2. Agency Information a. Agency’s Years in operation <br />b. Agency’s Purpose/Mission <br />c. Agency’s Types of Services Provided <br />d. Agency’s Experience with Programs <br />e. Other Pertinent Agency Information <br />f. Schedule of Positions <br />g. Living Wage <br />h. Agency Budget <br /> <br /> 3. Program Information <br />A separate Section 3 is <br />required for each program. <br />a. Human Services Needs Priority <br />b. Type of Program <br />c. Agency Collaboration <br />d. Summary of Program <br />e. Description of Identified Need <br />f. Description of Population to be Served <br />g. Program Staffing, Capacity, & Expertise <br />h. Program Implementation Timeline <br />i. Value of Investment <br />j. Impact of Reduced/No Allocation <br />k. Other Pertinent Information <br />l. Target Population/Beneficiary Chart <br />m. Work Statement <br />n. Program Budget, Detail, & Cost per Individual <br />FOR OFFICE USE ONLY <br />Received By ________ <br />Date/Time ___________/_________ <br />7