THIS FREE TECHNICAL ASSISTANCE IS ADMINISTERED BY:
The California Hispanic Commission on Alcohol & Drug Abuse, Inc.
For The California Department Of Alcohol & Drug Programs

A. APPLICANT INFORMATION

Date: Contact Person: Title:

Organization: Address:

City: State: Zip Code:

County: Phone: Fax #:

email: website:

B. ORGANIZATION DESCRIPTION
1. Please click on one of the following categories that best describes your organization

2. How did you hear about our TA services? (Please check one.)

3. Please write a brief description of your organization:

4. What is/are the primary funding source(s) for your organization?:


C. TECHNICAL ASSISTANCE INFORMATION
1. What kind of assistance is needed? (Check all that apply)

Please Describe:


Identify your primary goal(s) to be achieved through the requested technical assistance or training.

Goal:

Outcome 1:

Outcome 2:

Outcome 3:

Outcome 4:

2. Describe any previous attempts to address the TA need(s) or obtain consultation or other resources.
Also describe the results of those attempts :

3. Proposed training date(s) or timeline:

4. Estimated number of participants:

5. Where will consultation occur? :

6. Identify the geographic area(s) to be served by technical assistance or training service.

7. Please identify the population(s) that will be most impacted by the technical assistance or training services.

Gender:

Age Group:

9. If yes, please describe the resources your organization can provide (e.g., funding for consultation fee, photocopy
training materials, consultant’s travel costs, etc.) :

10. Are you requesting a specific consultant or consultants?

11. If yes, please specify...