Project Intake Form

Project Intake Form
Project Title
Descriptive title of the project
Project Applicant
Applicant's Legal Name
Applicant Address
Street Address
Street Address Line 2
City
State
Zip Code
Point of Contact
Person to contact for any communication about the project
Phone Number
Primary phone for Point of Contact
Email
Primary email for Point of Contact
All counties in the North Central region are currently transitional.

(Additional county economic levels include distressed, at-risk and attainment)
Select all counties the project will serve.

CameronClearfieldElkJeffersonMcKeanPotterOther (Please include County and State)
Project Type
Primary Funding Agency
Please enter the Primary Funding Agency
Select Primary Objective to Set the Goal Supporting Objective

Project Funding

(Construction applications require attachment of an Engineering Cost Estimate)
Please enter the project funding amounts for each below. Totals and Percent will calculate automatically. Do NOT include the "$."

Funds Status

Construction applications require attachment of an Engineering Cost Estimate. Please upload an Engineering Cost Estimate, if applicable. Must be on letterhead.

File size limit: 9.8MB
Cancelof

Period of Performance
Start and End Date
Purpose of Project
Statement describing the purpose of this project.
Project Description
Describe major activities to be conducted (describing the who, what, when, where and how for each)
Explain the following for the Strategic Rationale:
- Identify the historic problems and/or opportunities the project will address.
- Explain the existing conditions or critical circumstances that would compel the funding of this project.
- Describe how the project supports a regional strategy or plan.
- Explain how this project will contribute to sustainable economic development in the service area impacted.
- Identify the types and numbers of jobs to be created or retained.
- Explain any Leveraged Private Investment because of this project.
Strategic Rationale
Collaborative Partnerships
Identify local, regional, state and/or federal partnerships that will support the project. What will their roles be?
Project Sustainability and Capacity
Explain previous experience in managing federal funding and how project will be sustained when funding is no longer available.

Output and Outcome Measures
Output Measure
Outcome Measure
Congressional and Legislative Districts
Miscellaneous Notes
Additional information relevant to the better understanding of proposed project.
Should be Empty: