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<br />FY06 Homeland Security Grant Program (HSGP) <br />Application Cover Sheet for Port Authorities - Applicant <br /> <br />Authorized Agent Information: <br /> <br />Contact Information: <br /> <br />Mailing Address <br /> <br />Name/Title <br /> <br />City, State, Zip Code <br /> <br />Area CodelOffice Telephone Number <br /> <br />E-Mail Address <br /> <br />Requested <br /> <br />Approyed <br />(for OHS use only) .' <br /> <br />Total $ <br /> <br />$,,' <br />.'.\:rf/i <br /> <br />Statement of Certification - Authorized Agent <br /> <br />By signing below, I hereby certifY I am the Authorized Agent and have the authority to apply for the FY 2006 <br />Homeland Security Grant Program, and this port authority's application represents the needs for the State <br />Homeland Security Program and Urban Areas Security Initiative program, as applicable. <br /> <br />Signature of Authorized Agent <br /> <br />Printed Name <br /> <br />Title <br /> <br />Date <br /> <br />For State use ONLY <br /> <br />Application reviewed/Grant award approved by: <br /> <br />Name <br /> <br />Date <br /> <br />Grant Performance Period: <br /> <br />OES ill # <br /> <br />Grant # <br /> <br />FY06 Homeland Security Grant Program <br /> <br />Page 40 <br /> <br />