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:12/08/2008NA5a. Federal Entity Identifier: * 5b. Federal Award Identifier:NAState Use Only:6. Date Received by State: 7. State Application Identifier:8. APPLICANT INFORMATION:* a. Legal Name: Virginia Public Health Association* b. Employer/Taxpayer Identification Number (EIN/TIN): * c. Organizational DUNS:541063425 167254031d. Address:* Street1: Street2:* City: County:* State: Province:* Country:* Zip / Postal Code:RichmondVA: VirginiaUSA: UNITED STATES232299606 Georges Bluff Roade. Organizational Unit:Department Name: Division Name:NA NAf. Name and contact information of person to be contacted on matters involving this application:Prefix:Middle Name:* Last Name:Suffix:* First Name:BarbosaMs. CeciliaTitle: Executive DirectorOrganizational Affiliation:Virginia Public Health Association* Telephone Number: Fax Number: 8047677230* Email: cecilia.barbosa@vapha.orgTracking Number: GRANT00555497 Funding Opportunity Number: CDC-PA-HM09-901 Received Date: 2008-12-08 16:40:54.000-05:00 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.):Commonwealth of Virginia* 15. Descriptive Title of Applicant's Project:NCEH-500.1.6 Built Environment/Healthy Community DesignAttach supporting documents as specified in agency instructions.Tracking Number: GRANT00555497 Funding Opportunity Number: CDC-PA-HM09-901 Received Date: 2008-12-08 16:40:54.000-05:00 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:VA-allVA-allAttach an additional list of Program/Project Congressional Districts if needed.17. Proposed Project:* a. Start Date:03/01/2009* b. End Date:02/28/201018. Estimated Funding ($):* a. Federal* b. Applicant* c. State* d. Local* e. Other* f. Program Income* g. TOTAL0.005,000.005,000.000.0018,750.0073,312.3044,562.30* 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:BarbosaCecilia* Title: Executive Director* Telephone Number: Fax Number: 8047677230* Email: cecilia.barbosa@vapha.org* Signature of Authorized Representative: * Date Signed: Cecilia Barbosa 12/08/2008Authorized for Local Reproduction Standard Form 424 (Revised 10/2005) Prescribed by OMB Circular A-102Tracking Number: GRANT00555497 Funding Opportunity Number: CDC-PA-HM09-901 Received Date: 2008-12-08 16:40:54.000-05:00 Time Zone: GMT-5
