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:12/08/20085a. 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: BlazeSports America, Inc* b. Employer/Taxpayer Identification Number (EIN/TIN): * c. Organizational DUNS:58-2087265 007141901d. Address:* Street1: Street2:* City: County:* State: Province:* Country:* Zip / Postal Code:AtlantaGA: GeorgiaUSA: UNITED STATES30339280 Interstate North Circle, Suite 450e. Organizational Unit:Department Name: Division Name:f. Name and contact information of person to be contacted on matters involving this application:Prefix:Middle Name:* Last Name:Suffix:* First Name:GalicMaraTitle:Organizational Affiliation:* Telephone Number: Fax Number: 770-850-8199* Email: mgalic@blazesports.orgTracking Number: GRANT00555391 Funding Opportunity Number: CDC-PA-HM09-901 Received Date: 2008-12-08 15:27:43.000-05:00 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:M: Nonprofit with 501C3 IRS Status (Other than Institution of Higher Education)Type 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.):* 15. Descriptive Title of Applicant's Project:BlazeSports National Disability Sports Conference, Innovate, Connect, Inspire: Making ConnectionsAttach supporting documents as specified in agency instructions.Tracking Number: GRANT00555391 Funding Opportunity Number: CDC-PA-HM09-901 Received Date: 2008-12-08 15:27:43.000-05:00 Time Zone: GMT-5
