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721 Capitol Mall, Sacramento, CA 95814 <br />· SASP Form No. 201 (10-77) <br /> <br /> STATE OF CALIFORNIA <br /> APPLICATION FOR ELIGIBILITY <br />FEDERAL SURPLUS PERSONAL PROPERTY PROGRAM <br /> <br />Before preparing this application, please read carefully the definitions given under Part B. Fill out all' applicable sections. <br />Part A. <br />Legal name of or anization CITY OF PLEASANTON Telephone(415) 577-1332 <br />Address ~. 0. Box 3247 City San Leandro County Alameda ZIP 94566 <br /> <br />I. Application is being made as a (please check one) (a) Public agency rxl or (b) Private, nonprofit and tax-exempt educational or public <br /> health organization f'l. Please provide evidence that the organization is a public agency or enclose a copy of the letter or certificate from <br /> the United States Internal Revenue Service evidencing tax-exemption under Section 501 of the Internal Revenue Code of 1954. <br />2. Check type of agency or organization and attach a supplement to this application describing the program operations and activities. For <br /> private, nonprofit organizations, the following additional information is required: (a) For educational institutions, include a description <br /> of the carriculum, the number of days in the school year, and the number and qualifications of the faculty or staff; (b) If a public health <br /> institution or organization, include a degcription of the health services offered, qualifications of staff and, if applicable, the number of <br /> beds, number of resident physicians, and number of registered nurses on the staff. <br /> <br />PUBLIC AGENCIES: Check either state []0r lo~al IZ [] Conservation <br /> I~ Economic development <br /> FI Education <br /> Grade level <br /> (Preschool, uninnitl,) <br /> Enrollment <br /> No. of school sites /~ <br /> ~ Parks and recreation <br /> G~ Public health <br /> ~ Public safety <br /> ~ Two or more of above <br /> FI Other (specify) <br /> <br />NONPROFIT INSTITUTION OR ORGANIZATION: <br /> []. Education <br /> <br /> Grade level (Preschool, university) <br /> EnrOllment <br /> No. of school sites <br />f'l School for the mentally or physically handicapped <br />F1 Educational radio or television station <br />[] Museum <br />[] Library <br />[] Medical institution <br />[] Hospital <br />[] Ilcalth center <br />[] Clinic <br />I'l Other (specify) <br /> <br />3. Check if the applicant program is approved []; accredited []; or licensed F1. Enclose evidence of such approval, accreditation, or <br /> · licensing. If the applicant lacks evidence of formal approval, accreditation, or licensing, check here '[] and refer to the enclosed <br /> instructions. <br /> <br />4. Are the applicant's services avaihble to the public at large? <br /> comprises this group. <br /> <br />Yes . If only a specified group of peopl~ is served, please indicat0 who <br /> <br />5. Checklist of attachments submitted with this application: , <br /> [] Evidence that applicant's program is a public agency or exempt from paying taxes under Section 501 of the 1RS Code of 1954 <br /> li] DescriptiOn of program operations and activities <br /> [] Evidence of approval, accreditation, or licensing or information submitted in lieu Sereof <br /> [] SASP Form No. 202, "Resolution," properly signed, designating representatives authorized to bind the applicant to the terms and <br /> conditions governing the transfer of federal surplus personal property <br /> fJ SASP Form No. 203, nondiscrimination compliance assurance <br /> [] Statement concerning applicant's needs, resources, and ability to utilize the property <br /> [] Other statements or ~documentation required, as specified in the instructions, for certain categories of applicants. <br /> <br />wte: cx Y M GER <br />FOR STATE AGENCY USE <br /> <br />Application approved: <br />Comments or additional information: <br /> <br />Application disapproved: <br /> <br />Date: Signed: <br /> Director <br /> <br /> <br />