Reaching Rural Individual Application

This application form should be used if you are applying as an individual and not as a team. Click here if you are applying as a team and not as an individual.

In addition to completing your individual application form and the essay questions via this online form, you must provide a letter of support from your agency director if you are not an elected official, judge, or agency/department director. You will be able to upload this letter via the last page of this form.

All required application components must be submitted no later than 5:00pm ET on December 15, 2023. Applicants will receive a notice of submission upon completion of the online application. Questions about your application? Please send an email to COSSUP@iir.com and we will respond to your inquiry promptly.

Applicant Information *This question is required.

First Name *This question is required.

Last Name *This question is required.

Job Title *This question is required.

Office/Agency *This question is required.

Phone Number *This question is required.

Email Address *This question is required. This question requires a valid email address.

Applicant Employer Information *This question is required.

Applicant Agency/Organization Legal Name *This question is required.

Street Address *This question is required.

City or County *This question is required.

State *This question is required.

Employer Identification Number *This question is required.

Type of Applicant *This question is required.

Please enter an 'other' value for this selection.

What is the geographic location served by your agency? *This question is required.

What is the population size of the community/communities to be served by this project *This question is required.

Is the community of focus for this application considered rural as defined by the Rural Health Grants Eligibility Analyzer? *This question is required.

If not, provide justification for why you believe your jurisdiction is rural. *This question is required.