Free Cover Sheet For Proposals to the Federal Aviation Administration - Federal

U.S. Department of Transportation Federal Aviation Administration

COVER SHEET FOR PROPOSALS TO THE FEDERAL AVIATION ADMINISTRATION
SOLICITATION NUMBER

Form Approved: O.M.B. No 2120-0559 11/30/2006

FOR CONSIDERATION BY FAA ORGANIZATION UNIT
Indicate the most specific unit known i.e. program, division, etc. EMPLOYER IDENTIFICATION NUMBER (EIN) or TAXPAYER IDENTIFICATION NUMBER (TIN)

SHOW PREVIOUS GRANT NUMBER IF THIS IS A SUPPLEMENT TO AN EXISTING GRANT

IS THIS PROPOSAL BEING SUBMITTED TO ANOTHER IF YES, LIST NO FEDERAL AGENCY? YES ACRONYM(S)

NAME OF ORGANIZATION TO WHICH AWARD SHOULD BE MADE:

INSTITUTION NAME (IF KNOWN)

ADDRESS OF ORGANIZATION (INCLUDE ZIP CODE)

CONGRESSIONAL DISTRICT SUBMITTING ORGANIZATION

COUNTY

ACADEMIC INSTITUTION

NON-PROFIT ORG

FOR-PROFIT ORG

OTHER

BRANCH/CAMPUS/OTHER COMPONENT (Where work is performed, if different from above) TITLE OF PROPOSED PROJECT: REQUESTED AMOUNT: PROPOSED DURATION REQUESTED STARTING DATE

PI/PD DEPARTMENT NAMES (TYPED) PI/PD E:MAIL ADDRESS CO-PI/PD CO-PI/PD CO-PI/PD

PI/PD PHONE NUMBER PROFESSIONAL TITLE

PI/PD FAX NUMBER SIGNATURE

By signing and submitting this proposal, the authorized official of the applicant institution is providing certification regarding federal debt status, debarment and suspension, drug-free workplace, and lobbying activities (If answering "yes" to either, please provide explanation.) Is the organization delinquent in any Federal debt? Is the organization or its principals presently debarred, suspended, proposed for debarment, declared ineligible, or voluntary excluded from covered transactions by any Federal department or agency? YES NO

AUTHORIZED INSTITUTIONAL REPRESENTATIVE NAME/TITLE (TYPED) TELEPHONE NUMBER
FAA Form 9550-1 (03-03) Supersedes Previous Edition

SIGNATURE

DATE

FAX NUMBER

CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
(GRANTEES OTHER THAN INDIVIDUALS)

This certification is required by the regulations implementing the Drug-Free Workplace Act of 1986, 49 CFR 29, Subpart F. These require certification by grantees, prior to award, that they will maintain a drug-free workplace. The certification set out below is a material representation of fact upon which reliance will be placed when the agency determines to award the grant. False certification or violation of the certification shall be grounds for suspension of payment, suspension or termination of grants, or government wide suspension or debarment

The grantee certifies that it will provide a drug-free workplace by:

a)

Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the grantee's workplace and specifying the actions that will be taken against employees for violation of such prohibition; Establishing a drug-free awareness program to inform employees about1) 2) 3) 4) The dangers of drug abuse in the workplace;
The grantee's policy of maintaining a drug-free workplace;
Any available drug counseling, rehabilitation, and employee assistance programs; and, The penalties
that may be imposed upon employees for drug abuse violation occurring in the workplace;


b)

c) d)

Making a requirement that each employee to be engaged in the performance of the grant be given a copy of the statement required by paragraph (a); Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the grant, the employee will1) 2) Abide by the terms of the statement; and Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five days after such conviction:

e)

Notifying the agency within ten days after receiving notice under subparagraph (d) (2), from an employee or otherwise receiving actual notice of such conviction; Taking one of the following actions, within 30 days of receiving notice under subparagraph (d) (2), with respect to any employee who is convicted1) 2) Taking appropriate personnel action against such an employee, up to and including termination; or Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State or local health, law enforcement, or other appropriate agency;

f)

g)

Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs (a), (b), (c), (d), (e), and (f).

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THIS PAGE MUST BE SUBMITTED AS PART OF THE PROPOSAL

CERTIFICATION REGARDING LOBBYING
Certification for Contracts, Grants, Loans, and Cooperative Agreements. The undersigned* certifies, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned,* to any person for influencing, or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of and Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress or an employee of a Member of Congress in connection with this Federal contract, grant, loan or cooperative agreement, the undersigned* shall complete and submit standard Form-LLL, ''Disclosure Form to Report Lobbying,'' in accordance with its instructions.

(3) The Undersigned* shall require that the language of this certification b included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U. S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Statement for Loan Guarantees and Loan Insurance The undersigned* states, to the best of his or her knowledge and belief, that: If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned* shall complete and submit Standard Form-LLL, ''Disclosure Form to Report Lobbying,'' in accordance with its instructions. Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $1 0,000 and not more than $1 00,000 for each such failure.

*By signing the Cover Sheet and submitting this page as part of the proposal, the applicant is providing Certification Regarding Lobbying

PAPERWORK REDUCTION ACT
Paperwork Reduction Act Statement: This form is used by applicants to submit proposals in response to the Congressionally mandated Grants Program. The collection of data is required to adhere to the statutes and OMB circulars. It is estimated that it will take approximately 2 hours to complete the form. Use of the form is mandatory. No assurance of confidentiality is necessary or provided. It should be noted that 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 OMB control number associated with this collection of information is 2120-0559. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA-20

FAA Form 9550-1 (03-03) Supersedes Previous Edition

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