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Inclusive Community: Universal Changing Table Grant Request Form
Please complete the application form in its entirety, incomplete applications will be returned.
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Email
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Your email
Agency/Organization Name:
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Your answer
Contact Name:
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Your answer
Address:
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Your answer
Telephone Number:
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Your answer
What current or upcoming project is a universal changing table and/or space being requested for?
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Your answer
What is the total cost of this project?
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Your answer
If more than $75,000, was it competitively bid?
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Yes
No
Not Applicable (Less than $75,000)
Are you able to acquire a universal changing table by contacting the vendor directly or do you need assistance from Auglaize DD?
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I will contact the vendor.
I need help from Auglaize DD.
Certification Statement: By electronically printing my name below, I confirm that all the information provided above is true and correct to the best of my knowledge. I also understand that if approved, I agree to provide project status updates that may be required to fulfill Auglaize DD ARPA reporting requirements.
(Print Name & Date Below)
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Your answer
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