Requestor Information

Hands United / Manos Unidas Technical Assistance Services

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1. TA provider (Required.)

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2. Requesting Organization (Required.)

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3. First Name: (Required.)

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4. Last Name: (Required.)

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5. Title:

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6. Email Address: (Required.)

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7. Please re-enter email address: (Required.)

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8. Phone number:

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9. Please select the technical assistance services you are interested in: (Required.)

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10. Describe the specific challenge or barrier you are experiencing. (Required.)

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11. What would you like to accomplish as a result of this TA request? (Required.)

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12. Who else should we contact?

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13. Who are the proposed activities targeted towards (i.e., specific groups or individuals who will be the recipients of these activities)?

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14. When would you like the request to begin?

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15. Funding Source: Direct CDC Funding

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16. If YES, have you talked with your CDC Project Officer about this request?

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