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FLP State Affiliate Application State: _________________________ Date: _____/_____/_____ State Affiliate's Name: ____________________________________________________ Address: __________________________________________ City: ________________ State: ____ Zip: ______________ Contact Person: ___________________________________ Telephone: _________________ Fax: ____________________ E-mail: __________________________ Type of Organization:
____ 501(c)(3) ____ Incorporated ____ Other (list) ___________________________________ Fiscal Agent (if different than primary affiliate) _____________________________________ Contact Person: ___________________________________ Telephone: _________________ Address: __________________________________________ City: ________________ State: ____ Zip: ______________ Estimated First Year Budget: $________________ State Coordinator's Name: ___________________________________ Contact Address: __________________________________________ City: ________________ State: ____ Zip: ______________ Telephone: _________________ Fax: ____________________ _____ Full time or _____ Part time Hours/Week _____ Starting Date: _____/_____/_____ Proposed Date(s) for Facilitator Training: ____/________/____ or ____/________/____ Estimated Number of Facilitators to be trained: ________ Proposed Location of Training: ___________________________________________ Are you willing to combine with another state for this training? _____ Yes _____ No Coalition Members Supporting this Application We, the undersigned, support the ________________________________ as our State Affiliate and will work in cooperation with them to distribute, use and market the Project Food, Land & People Resources for Learning in ____________________(state). Dated ____/____/____
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