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<br />FY06 Homeland Security Grant Program <br />Application Cover Sheet for State Organizations (Page 1 of 3) <br />Applicant (State Organization) <br /> <br />Authorized Agent Information: <br /> <br />Contact Information: <br /> <br />Mailing Address <br /> <br />NamelTitle <br /> <br />City, Slale, Zip Code <br /> <br />Area Code/Office Telephone Number <br /> <br />E-Mail Address <br /> <br />Maximum Amonnt Authorized <br /> <br />$ <br /> <br />SHSP Amount Requested $ <br /> <br />LETPP Amount Requested $ <br /> <br />UASI Amount Requested $ <br /> <br />Total Amount Requested $ <br /> <br />Statement of Certification - Authorized Agent <br /> <br />By signing below, I hereby certifY [ am the duly appointed Authorized Agent and have the authority to apply for <br />the FY 2006 Homeland Security Grant Program, and this state organization's application represents the needs <br />for the State Homeland Security Program, Law Enforcement Terrorism Prevention Program and Urban Areas <br />Security Initiative program, as applicable, <br /> <br />Signature of Authorized Agent <br /> <br />Printed Name <br /> <br />Title <br /> <br />Date <br /> <br />Application reviewed/Grant <br /> <br /> <br />Grant Performance Period: <br /> <br />OES ID # <br /> <br />Award # <br /> <br />FY06 Homeland Security Grant Program <br /> <br />Page 37 <br />