5800-092 EJ TCTAC Intake Form Center B

OMB Control Number: 2030-0051

Expiration Date: 05/31/2024

EJ TCTAC Intake Form Center B

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2030-0051. 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 15 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.

Required: The collection of information required for the rendering of appropriate services deployed by Center B

General information

Organization Name:

Organization Type:

Physical Address:

___________________________________ ___________________________________

__________________________________ ____________________________________

Municipality/County: ________________________________ Zip Code: _____________

Main Point of Contact

First Name: ____ ____

Last Name: _ ____

Position and Title: _

Email: (Please enter your preferred email that is checked regularly. This is our primary form of communication.)

Telephone: ____

Organization Information:

Date of Incorporation of the Organization:

Mission of the Organization:

Your organization main activities:

Environmental:

Energy:

How did you learn about this Technical Assistance Center?

• Referred by TA Provider

• EPA/DOE Website

• Interamerican University of Puerto Rico Website/Newsletter

• TA Provider Website (Vitrina Solidaria, Energy Justice for Puerto Rico, New Jersey Institute of Technology, WEACT, Environmental Protection Network or Engineers without Border)

• Social Media (LinkedIn, Facebook, Instagram, Twitter)

• News/ Press Release Article

• Other

Project Details:

Please provide details on the technical assistance you are requesting, including specific questions (e.g. sam.gov registration, grants.gov registration and grant opportunities, eligibility, grant writing/review, feasibility study, other requirements, etc.) The more details you can provide, the quicker we can connect you to our TA network.

1. Collaborative Problem-Solving Model 7 steps used by EPA (Issue Identification, Strategic Goals, Community Capacity Building and Leadership)

2. Business Canvas Boot Camp (Identity, Mission, Vision, SWOT)

3. Environmental Justice and Advocacy (Effectively engage with stakeholders)

4. Energy Justice and Advocacy (Energy Project Design and Implementation)

5. Grant writing and grantsmanship (Training in competitive proposal writing

6. Technical Assistance in funding opportunities

7. Technical Assistance in grant submission (SAM.gov or Grants.gov)

I understand that the ECO-EAGLE program does not offer or provide contractor services or financial capital. It does not offer grant writing or project management services, nor does your voluntary use of EAGLE guarantee the success of a grant application or the grant funding for your project.*

EPA Form: 5800-092