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MIDWEST REGION 5 TCTAC INTAKE FORM
Please complete this form to the best of your ability as a first step in the process - this will allow us to better understand your needs. One of our TCTAC team members will be in touch once we receive your submission.

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be between 20 and 30 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
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Organization Name *
Organization Address *
City, State, Zip Code *
Organization Website *
Contact Person Full Name *
Contact Person Email Address *
Contact Person Phone Number *
Please check the service(s) that best applies to your inquiry. *
Required
What challenges or problems are you seeking to address? (Please provide a detailed description) *
What do you currently have in place for your target areas of concern? What previous actions were taken to address your concerns?
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What are your top priorities/goals? (Please list in order of importance)
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What does a successful outcome look like to you?
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What budget/financial constraints do you need to work within?
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What experience do you have applying for and managing government grants?
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Are you registered with Grants.gov?
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Are you registered with SAM.gov?
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Are there any specific deadlines or timeframes that should be adhered to?
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Please describe your current organization/staff capacity and needs. Who are the key decision-makers for your organization? (Please include names, email addresses, and phone numbers)
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Additional Information (Please add any additional information that may be pertinent for our team to make the most informed decision(s) regarding your inquiry)
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