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'Z 2-AS- DEPARTMENT OF GENERAL SERVICES SASP Form 201 (02/2000) PROCUREMENT DIVISION www.pd.dge.ca.gev/matadaisl/surplus.esp SURPLUS PROPERTY 1700 NATIONAL DRIVE New SACRAMENTO, CA 95834-1965 STATE OF CALIFORNIA (916) 928-4630 APPLICATION FOR ELIGIBILITY FEDERAL SURPLUS PROPERTY PROGRAM Before preparing this application, please read carefully the definitions given under Part B. Fill out all applicable sections. A. Name of Organization C:[.cy of ~Eedwood City - Pol:tee ]~e.~-.'l'elephone 650-780-7100 Address 1301 ~[aple St:. City ~.edwoo~t C-II:? County San t4.at:eo Zip. 94063 1. Application is being made as a (please check one) (a) Public agency x_.. or (b) Pdvate, nonprofit and tax-exempt educational or public health organization __ Please provide evidence that the organization is a public agency or enclose a copy of the letter or certificate from the United States Intemal Revenue Servic~ evidencing tax-exemption under Section 501 of the Internal Revenue Code of 1954. 2. Check type of agency or organization and attach a supplement to this application describing the program ogeraflons and activities. For private, nonprofit organizations, the following additional information Is required: (a) For educational institutions, include a description of the curriculum, the number of days in the school year, and the number and qualification of the faculty or staff;, (b) If a public health Institution or organization, include a description of the health services offered, qualifications of staff and, if applicable, the number of beds. the number of resident lYnysidans, and number of registered numes on the staff. PUBLIC AGNECY: Check either state or local ~ NONPROFIT AGENCY OR ORGANIZATION: Conservation __Education Economic Development Grade level Education (Preschool, Univemtty) Grade Level Enrollment (Preschool, university) No. of school sites Enrollment School for the mentally or physically handicapped No. of school sites Educational radio or television station ~ Parks & Recreation Museum Public Health Library ~ Public Safety __Medical institution Two or more of above ~Hospital Other (specify) Health center Clinic Other (specify) 3. Check if the applicant program is approved ~; accredited ~; or licensed __. Enclose evidence of such approval, accreditation, or licensing. If the applicar lacks evidence of formal approval, accreditation, or licensing, check hem __ and refer to the enclosed instnJctions. 4. Are the applicant's services available to the public at large? Yes . If only a specified group of people is served, please indicate who comprises this group. 5. Checklist of attachments submitted with this application: Evidence that applicant's program is a public agency or exempt from paying taxes under Section 501 of the IRS Cede of 1954. Description of program operations and activities. Evidence of approval, accreditation, or licensing or information submitted in ifeu thereof. SASP Form No. 202. "Resolution,* property signed, designating representatives authorized to bind the applicant to the terms and conditions governing the transfer of federal surplus personal property. SASP Form No. 203, nondiscrimination compliance assurance, Statement conceming applicant's needs, resources, and ability to utilize the property. Other statements or documentation required, as apecifled in the instructions, for certain categories of applicants. Date: Signed: Title: FOR STATE AGENCY USE Applications al)proved Applications disapproved. Comments or additional ~nformation: Date: Signed: