ECECD Childcare Technology Grant

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Grant Description

Before you start...

Applicant Contact Information

Applicant Name*

First Name

Last Name

County *

Phone*

Email*

Name of Childcare Center, Licensed Home, or Registered Home you are affiliated with*

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Is your mailing address a PO Box?*

Yes No

Please enter a physical address. Your equipment cannot be shipped to a PO Box*

Address Line 1

Address Line 2

City

State

ZIP Code

Supporting Documents

1099 Acknowledgement*

By clicking here, I acknowledge that I will receive a 1099 tax form for the value of the technology I recieve to be included on my 2021 taxes.

Please Upload Your Completed & Signed W-9 Here. *Please upload your personal W-9. This technology equipment will be your property, not the centers.* No File Chosen

File uploads may not work on some mobile devices.

*Need a W-9 form? Go to www.crecnm.org & click “visit our news page"

Proof of Childcare Employment: Please upload your paystub. If you do not recieve a paystub, please upload your Home License, Home Registration, or childcare work schedule signed by the Owner or Director of the childcare center.* No File Chosen

File uploads may not work on some mobile devices.

E-Signature

By signing below, I certify the information I provided on this form and with this form is true and correct to the best of my knowledge.

Applicant Signature*

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Date*

Grant Description

Before you start...

Applicant Contact Information

Technology Requests

Supporting Documents

E-Signature