OMB Number: 4040-0004Expiration Date: 01/31/2009Application for Federal Assistance SF-424 Version 02* 1. Type of Submission:m Preapplicationl Applicationm Changed/Corrected Application* 2. Type of Application: * If Revision, select appropriate letter(s):l Newm Continuation * Other (Specify)m Revision* 3. Date Received: 4. Applicant Identifier:12/05/20085a. Federal Entity Identifier: * 5b. Federal Award Identifier:State Use Only:6. Date Received by State: 7. State Application Identifier:8. APPLICANT INFORMATION:* a. Legal Name: The University of Illinois at Chicago* b. Employer/Taxpayer Identification Number (EIN/TIN): * c. Organizational DUNS:376000511 098987217d. Address:* Street1: Street2:* City: County:* State: Province:* Country:* Zip / Postal Code:502 MB, M/C 551ChicagoCookIL: IllinoisUSA: UNITED STATES60612-7205809 S. Marshfield Avenuee. Organizational Unit:Department Name: Division Name:Department of Psychology Community& Prevention Researchf. Name and contact information of person to be contacted on matters involving this application:Prefix:Middle Name:* Last Name:Suffix:* First Name:DanzingerPharm.D.Dr. LarryTitle: Vice Chancellor for ResearchOrganizational Affiliation:Office of Research Services* Telephone Number: Fax Number: 312-996-2862 312-996-9005* Email: awards@uic.eduTracking Number: GRANT00553581 Funding Opportunity Number: CDC-PA-HM09-901 Received Date: 2008-12-05 16:33:09.000-05:00 Time Zone: GMT-5 OMB Number: 4040-0004Expiration Date: 01/31/2009Application for Federal Assistance SF-424 Version 029. Type of Applicant 1: Select Applicant Type:H: Public/State Controlled Institution of Higher EducationType of Applicant 2: Select Applicant Type:Type of Applicant 3: Select Applicant Type:* Other (specify):* 10. Name of Federal Agency:Centers for Disease Control and Prevention11. Catalog of Federal Domestic Assistance Number:93.283CFDA Title:Centers for Disease Control and Prevention_Investigations and Technical Assistance* 12. Funding Opportunity Number:CDC-PA-HM09-901* Title:Public Health Conference Support Program13. Competition Identification Number:NCHM-NRTitle:14. Areas Affected by Project (Cities, Counties, States, etc.):Chicago, Cook, Illinois* 15. Descriptive Title of Applicant's Project:NCCDPHP-400.1.1 Health Promotion in Global ContextAttach supporting documents as specified in agency instructions.Tracking Number: GRANT00553581 Funding Opportunity Number: CDC-PA-HM09-901 Received Date: 2008-12-05 16:33:09.000-05:00 Time Zone: GMT-5 OMB Number: 4040-0004Expiration Date: 01/31/2009Application for Federal Assistance SF-424 Version 0216. Congressional Districts Of:* a. Applicant * b. Program/Project:IL-007IL-007Attach an additional list of Program/Project Congressional Districts if needed.17. Proposed Project:* a. Start Date:04/15/2009* b. End Date:04/14/201018. Estimated Funding ($):* a. Federal* b. Applicant* c. State* d. Local* e. Other* f. Program Income* g. TOTAL4,500.000.000.000.000.00177,364.00172,864.00* 19. Is Application Subject to Review By State Under Executive Order 12372 Process?m a. This application was made available to the State under the Executive Order 12372 Process for review onm b. Program is subject to E.O. 12372 but has not been selected by the State for review.l c. Program is not covered by E.O. 12372..* 20. Is the Applicant Delinquent On Any Federal Debt? (If 'Yes', provide explanation.)m Yes l No21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statementsherein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to com-ply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims maysubject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)4o ** I AGREE** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agencyspecific instructions.Authorized Representative:Prefix:Middle Name:* Last Name:Suffix:* First Name:DanzingerPharm.D.Larry* Title: Vice Chancellor for Research* Telephone Number: Fax Number: 312-996-2862 312-996-9005* Email: awards@uic.edu* Signature of Authorized Representative: * Date Signed: Larry Danziger 12/05/2008Authorized for Local Reproduction Standard Form 424 (Revised 10/2005) Prescribed by OMB Circular A-102Tracking Number: GRANT00553581 Funding Opportunity Number: CDC-PA-HM09-901 Received Date: 2008-12-05 16:33:09.000-05:00 Time Zone: GMT-5
