PAGE 2                                                                                                                                                                                                                                WEEB 1

        CONSORTIUM VERIFICATION FORM

 

 

 

Each of the undersigned certifies that they will participate in this project, that the specified obligations and responsibilities in this project will be met, and that the project will be administered by the public agency or corporation designated.

 

 

                                                                                                  ADMINISTERING ORGANIZATION

 

Organization’s Name

 

 

Project Director's Name
Project Title Telephone Area/No.

 

 

                                                                                               PARTICIPATING ORGANIZATION(S)

 

 Organization’s Name

 

 

Telephone Area/No.

Address (Street, City, State, Zip)

 

Supplying 1/3 or More of the Total Match?

o Yes                                   o No

Name and Title

 

 

Signature

 

Ø

Date Signed

 Organization’s Name

 

 

Telephone Area/No.

Address (Street, City, State, Zip)

 

Supplying 1/3 or More of the Total Match?

o Yes                                   o No

Name and Title

 

 

Signature

 

Ø

Date Signed

 Organization’s Name

 

 

Telephone Area/No.

Address (Street, City, State, Zip)

 

Supplying 1/3 or More of the Total Match?

o Yes                                   o No

Name and Title

 

 

Signature

 

Ø

Date Signed

 Organization’s Name

 

 

Telephone Area/No.

Address (Street, City, State, Zip)

 

Supplying 1/3 or More of the Total Match?

o Yes                                   o No

Name and Title

 

 

Signature

 

Ø

Date Signed
     

 

Use a duplicate of this form if there are more than four participating organizations.                                                                              WEEB(Rev. 6/06)