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APPLICATION SUBMITTAL CHECKLIST <br />Agency Orange County Rape Crisis Center <br />Program(s) Client Services & Community Education <br />i I P a g <br />1. Cover Page <br />a. <br />�VProjectlProgram pplicant Contact Information <br />b. <br />Contact Information <br />c. <br />© Funding Requests Identified <br />d. <br />[Signed Application Cover Page <br />2. Agency <br />a. <br />Agency's Years in operation <br />24 CFR 570.506, <br />Information - <br />b. <br />Agency's Purpose /Mission <br />570.507, 570.610, 24 <br />c. <br />[]Agency's Types of Services Provided <br />CFR Parts 84 or 85 <br />d. <br />Agency's Experience <br />e. <br />Other Pertinent Information <br />3. Program/ <br />a. <br />d ype of Application and Program Identified <br />24 CFR 570.200(a), <br />Project <br />b. <br />Summary of Program <br />570.201 -570. 208, <br />Information - <br />c. <br />escription of Identified Need <br />507.503 <br />(for each <br />d. <br />rVescription of Population to be Served <br />program/ <br />e. <br />[� ctivity Manager and Location Description <br />project for <br />f. <br />[Activity Implementation Timeline <br />which funding <br />g• <br />2"'4gency Collaboration <br />is requested) <br />h. <br />Q Describe Impact of Reduced /No Allocation <br />i. <br />[✓Other Pertinent Information <br />j. <br />Complete Target Population /Beneficiary Chart <br />k. <br />Q Complete Schedule of Positions <br />I. <br />[A Signed Conflict of Interest Disclosure <br />m. <br />Ef Complete Work Statement <br />i I P a g <br />