Check Information Make Check Payable To: County Name: Name Of School: SAFE Sponsor's Name: Sponsor's Phone Number (000-000-0000): Email Address: Send A Copy Of This Completed Form To Email Address: Shipping Information Please enter the shipping information for where the check should be mailed, in the fields provided below. School/Agency Name: Address: City: State: Zip Code (5 or 9 digits): Expenses Description Amount Additional Requests #1: Additional Requests #2: Additional Requests #3: Additional Requests #4: Additional Requests #5: Additional Requests #6: Additional Requests #7: Additional Requests #8: Additional Requests #9: Additional Requests #10: Additional Request Comments: Total Funding Requested: All funding is awarded based on availability of funds. An expense report and receipts will be required at the end of the school year to verify how these funds were used. I understand by submitting this form and requesting a grant from the Kansas Traffic Safety Resource Office and the Kansas Department of Transportation, I have committed to implement the SAFE program to its completion. Submitting the final survey marks completion of the program. Failure to complete the program will result in returning the grant dollars received. By typing your name and entering the date in the fields provided, you are e-signing this agreement. Enter Your First & Last Name: Today's Date: Submit Your Information
