Okaloosa County BOCC — January 7, 2014 — Traffic Education Fund - application

APPLICATION FOR OKALOOSA COUNTY TRAFFIC EDUCATION FUND DISBURSEMENTS AGENCY INFORMATION Okaloosa County Sheriff’s Office Agency Name: Okaloosa County School Board Program Name: Program Location: (name of school) Name/ Title of Agency Contact: Address: Phone: City • Zip Code: E-mail: New Renewal Amount Program is: P $ Requested: PROPOSED PROGRAM INFORMATION 1. Program Summary (1-3 sentences): Provide an overview of program services. 2. Proposed use of Okaloosa County Traffic Education Fund (1-3 sentences): Please identify the proposed use(s) of Okaloosa County Traffic Education Fund. These funds shall be used for direct educational expenses and shall not be used for administration. Specifically explain how these funds will be used for enhancement, and not replacement, of driver education program funds. 1  Upon completing this Application in its entirety, please read the following statement and affix your signature accordingly. I have read, fully understand and agree to be bound by Section 318.1215, Florida Statutes, and Chapter 21, Article V of the Okaloosa County Code of Ordinances (also known as Ordinance 11-17) as amended from time to time. I have completed this application fully and accurately and have not misrepresented any information contained herein. I certify that the requested funds will be used for the purposes set forth in this application and in conformity with applicable laws. Pursuant to Ordinance 11-17, I have submitted appropriate documentation of expenditures, programs, and other direct educational expenses along with this Application. I further agree that should I fail to provide any necessary follow-up documentation, I may be responsible for reimbursing Okaloosa County for the amounts received. Signature of Applicant Date of Application Print Name of Applicant OFFICIAL USE ONLY Board of County Commissioners: Approved/Disapproved Date: _________ Amount approved: $________ 2