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2. First Name*
3. Last Name*
5. Job Title*
7. Organization Name*
8. Email Address*
10. Organization Address*
12. City*
13. State*
14. Zip Code*
16. DUNS # *

    (Data Universal Numbering System)

17. Phone Number*
18. Alternate Contact*

    Name/Title/Email 

20. Type of Agency*
    -- Select One --Nonprofit Faith-basedHousing Developer (private or nonprofit)Government/Municipalities Other
22. Are You Registered in SAM?*
    -- Select One --YesNoUnsure

    (System for Award Management)

23. Are You In Good Standing With The CO SOS? *
    -- Select One --YesNoUnsure

    (Colorado Secretary of State)

25. Disclaimer

    Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.

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27. 1. Receive an email copy of this form.
28. Email address

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