Broad Agency Announcement ITC IPAC Atch 8 Coversheet and Principal Investigator Information

Instructions for Completion
Cover Page Completion
If there is information that is not applicable in any of the sections, please indicate that by marking “N/A”
Section 1
Fill out this section with the information of the organization that the contract will be formed with.
Section 2
Fill out this section with the organizations SAM registration information. If your organization is still completing your SAM registration, please select “In Progress.” Section 3
Fill out this section with the project information.
Section 4
Fill out this section with the information of the individual who can be contacted with questions about this application.
Section 5
Fill out this section with the amount of funding you are requesting from ITC IPAC. Section 6
Fill out this section with the information of the person authorized to sign the contract. Section 7
Fill out this section with the projects principal investigator’s information. Current & Pending Funding
The principal investigator should provide additional information on any additional support they are receiving for this project and any other projects.
Privacy Act Completion
The principal investigator should complete the “Covered Individual” and “Institution Name” Blocks.
Note: If you have other key personnel or investigators, please complete Attachment 9 with their information.

BROAD AGENCY ANNOUNCEMENT

FA520922S0001

PROJECT SUBMISSION COVERSHEET

DATE:

1.

APPLICANT INFORMATION

Legal Name/Organization Name:

Department/Division:

Address:

Country:

2.

APPLICANT SAM REGISTRATION INFORMATION

SAM Registration Status:

Active
SAM Expiration Date:

SAM UEI:

SAM CAGE:

Attachment 8

3.

APPLICATION POINT OF CONTACT

First Name:

Last Name:

Telephone Number:

Email:

Organization Affiliation/Position:

4.

PROJECT INFORMATION

Descriptive Title of Applicant’s Project:

Proposed Project Start Date:

Proposed Project End Date:

5.

ESTIMATED FUNDING INFORMATION

Total ITC IPAC Funds Requested:

6.

AUTHORIZED CONTRACT REPRESENTATIVE

First Name:

Last Name:

Telephone Number:

Email:

Organization Affiliation/Position:

7.

PRINCIPAL INVESTIGATOR INFORMATION

Prefix:

First Name:

Last Name:

Organization Name:

Position:

Department:

Phone Number:

Email:

List Degree(s) Type/Year:

List Previous Employment/Experience (include years):

List last five (5) publications and five (5) most closely related to the proposal:

CURRENT AND PENDING SUPPORT

The following information should be provided for each investigator and other senior personnel. Failure to provide the information may delay consideration of the proposal.