Please review NOFA No.2021-MBI-02 prior to submitting a grant application. Applicant Information Name of Municipality This field is required. Application Contact Name This field is required. Email Phone Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Title This field is required. Number of Hotspots Proposed Total Number of Hotspot Locations Proposed 1 2 3 Justification for More Than One Hotspot This field is required. Proposed Hotspot Description(s) Proposed Location #1 Name of Proposed Location This field is required. Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Hotspot Type Indoor Outdoor Hotspot Hours of Operation This field is required. Description of the Hotspot Location (including maximum user capacity) This field is required. Parking Capacity (e.g., # of parking spaces) This field is required. Handicap Accessible Yes No Accessible by Public Transportation Yes No Proposed Public Health Protections for Hotspot Users (e.g., cleaning and social distancing) This field is required. Proposed Location #2 Name of Proposed Location Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Hotspot Type Indoor Outdoor Hotspot Hours of Operation Description of the Hotspot Location (including maximum user capacity) Handicap Accessible Yes No Accessible by Public Transportation Yes No Proposed Public Health Protections for Hotspot Users (e.g., cleaning and social distancing) Proposed Location #3 Name of Proposed Location Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Hotspot Type Indoor Outdoor Hotspot Hours of Operation Implementation Approach Proposed approach to procurement or implementation Applicant Acknowledgement and Acceptance By clicking submit below and entering your name as a signature, you acknowledge the following statements: The individual submitting the Application is a duly authorized representative of the Applicant. The Applicant has read and understands the Notice of Funding Availability (NOFA) requirements. The Applicant acknowledges that all of the terms and conditions of the NOFA are mandatory. The Applicant certifies that they are in compliance with the terms, conditions and specifications contained in the NOFA. The Applicant acknowledges and understands the procedures for handling materials submitted to the Mass Tech Collaborative as set forth in the NOFA and agrees to be bound by those procedures. The Applicant agrees that the Mass Tech Collaborative shall not be liable under any circumstances for the disclosure of any materials submitted to the Mass Tech Collaborative pursuant to the NOFA or upon the Applicant’s selection. The Applicant understands that, if selected by the Mass Tech Collaborative, the Applicant and the Mass Tech Collaborative will execute an Agreement specifying the mutual requirements of participation. The Applicant certifies that the statements made in this Application are true and correct to the best of the Applicant’s knowledge. Signature of Applicant This field is required. Sign above CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Leave this field blank
