Please note: Field boxes will accept all information entered.

Organization Name

Address

Primary Contact

Job Title

Telephone

Fax

E-mail

Population(s) served (check all that apply):

Lesbian/Gay/Bisexual/Transgender
Substance Abuse
HIV/AIDS
Other

Can commit a minimum of 25 participants (paid, peer and/or volunteer staff) for each training session

Will file co-application to meet 25 participant minimum

Along with this form submit the following required written statements:

Statement of Need (one page maximum) – Use this statement to let us know the specific need(s) the agency wants to focus on using training and consultation.

Agency Goal List (half page maximum) - Outline specific goals the agency wants to achieve as a result of receiving training and consultation.

Our agency understands what is required if we are selected for HAP partnership and our options if we are not selected (see If selected..., If not selected...).

Applicants will receive confirmation of receipt of their application