Minnesota Department of Health
MIIC Regional Services RFP
Applicant Information Form
Instructions
Complete the Applicant Information Form and submit with other required Proposal forms to MDH by
4:00 p.m., October 15, 2015.
Applicant Information
Applicant Agency Legal Name:
Applicant Agency Address:
Main Office Phone Number:
Website Address:
Minnesota Tax ID Number:
Federal Tax ID Number:
Director of Applicant Agency
Name:
Title:
Address:
Phone Number:
Email:
Financial Contact of Applicant Agency
Name:
Title:
Address:
Phone Number:
Email:
Designated Contact Person for MIIC Regional Entity Services
Name:
Title:
Address:
Phone Number:
Email:
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Minnesota Department of Health
MIIC Regional Services RFP
County Membership in Regional Entity
Community
Key Partner
Health Board:
County:
Contact Name:
Phone
Number:
Email:
Counties Served and Requested Funding
Total Number of Counties Served:
Total MDH Proposed Budget
Total DHS Proposed Budget:
Total Proposed Budget:
$
$
$
Certification
I certify that the information contained herein is true and accurate to the best of my knowledge and that
I submit this application on behalf of the applicant agency.
Signature of Authorized Agent for Grant Agreement
Title
Date
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