Reaching Rural Cross-Sector Team Application

This application form should be used if your community is interested in applying for this opportunity as a cross-sector team. Please click here for the individual application form if you are applying as an individual and not as a team.

In addition to completing your team application form and the essay questions via this online form, you must provide letters of commitment from each team member and the agency director for each team member (if not the applicant). You will be able to upload those letters via the last page of this online 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.

Lead Applicant Organization *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.

Primary Contact for This Application *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.