Workplace Safety Grant Application

DIA Safety Grant Application

Progress

Organization Detail

Legal Name of Applicant Organization

Prior Grant Recipient

Year *

DBA of Applicant Organization

Organization FEIN

COMMBUYS Number

Primary Contact (Who Can We Contact)

Check if Grant Administrator

Primary Contact Email

Primary Contact Phone

Ext.

Secondary Phone

Ext

Phone Type

Organization Address

Organization Address Line 1

Organization Address Line 2

Zip

City

State

County

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Grant Administrator

Grant Administrator Email

Grant Administrator Phone

Ext

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Grant Consortium Detail

If this is a consortium application please check the checkbox below and add the names and information for each participating organization (up to 10).

Consortium Grant?

Consortium Listing

Select	Legal Name	Address 1	Address 2	City	State	Zip	County	FEIN

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More Details

Estimated Number of Employees in Organization

Tell Us About Your Organization (Min. 100 and Max 1000 Characters)

Estimated Number of Employees Being Trained

Tell Use About Your Training Goals (Min. 100 and Max 1000 Characters)

Requested training must connect to the work performed by the employee (s)

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Budget Summary

Budget Narrative (Min. 100 and Max 1000 Characters)

Please add detail of the classes you anticipate holding.

Class List (The Maximum Grant Request Maybe Up To )

Class(es):

Select	Topic	#	Total # of Trainers	Trainer Name(s)	Company	Cost

Requesting Amount:

Allowed:

Remaining Amount:

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Required Documents

Trainer Resumes