Delta Center Intent to Apply

Applicant Information

Thank you for your interest in the Delta Center for a Thriving Safety Net.

We ask that each association/counterpart team is asked to indicate their intent to apply by Tuesday, December 15, 2020 (one response per association/counterpart team). This action is non-binding; the purpose is to facilitate our planning for the review of applications.

Please contact deltacenter@jsi.com with questions.

1. What is the name of the lead organization? (no acronyms please) *This question is required.

2. Who is the primary contact for the lead organization? *This question is required.

First Name

Last Name

Job Title

Email Address

Phone Number (formatted as XXX-XXX-XXXX)

3. In which state is the lead applicant located? If other, please specify the geographic location of the lead organization. *This question is required.

4. If selected "Other" please specify below.

4. Which of the following describes the lead organization? *This question is required.

Please enter an 'other' value for this selection.

5. What is the name of the partner organization (if known)? (no acronyms please - indicate "pending" if the partner application is still being determined) *This question is required.

6. Would you like to be added to the Delta Center e-newsletter for updates about the CFP and other activities?