132-22 Form 1A- Strategic Plan for Funding Municipal Alliances - DMHAS Grant v1.pdf

Governor’s Council on Alcoholism and Drug Abuse FORM 1A DMHAS YOUTH LEADERSHIP GRANT - MUNICIPAL ALLIANCES Year One Grant Term: 7/1/22 – 3/14/23 APPLICANT MUNICIPALITY/IES: West Orange COUNTY: Essex ALLIANCE NAME: West Orange Municipal Alliance ALLIANCE WEBSITE: westorange.org ALLIANCE STREET ADDRESS: 66 Main Street TOWN: West Orange STATE: NJ ZIP: 07052 TELEPHONE: ( 973 ) 325-4105 Ext. FAX: ( 973 ) 325-9853 ALLIANCE CHAIRPERSON: William Sullivan, JD STREET ADDRESS: Scarinci Hollenbeck, 1100 Valley Brook Avenue, PO Box 790 TOWN: Lyndhurst STATE: NJ ZIP: 07071 EMAIL: wcsullivanjr13@gmail.com ALLIANCE COORDINATOR: Laura A. Van Dyke, LCSW STREET ADDRESS: 66 Main Street TOWN: West Orange STATE: NJ ZIP:07052 EMAIL: lvandyke@westorange.org DATE OF RESOLUTION AUTHORIZING THE STRATEGIC PLAN (MM/DD/YYYY): 05 /24 / 22 DMHAS Grant Allocation $ 7,621.51 No Cash Match or In-Kind Match is required to accept DMHAS Grant. West Orange Mayor Parisi _________________________ __________________________________ ____________________________ *MUNICIPALITY NAME/ MAYOR/Head of Governing Body SIGNATURE West Orange Susan McCartney, Council President _________________________ __________________________________ ____________________________ *MUNICIPALITY NAME/TITLE OF GOVERNING SIGNATURE BODY REPRESENTATIVE _________________________ __________________________________ ____________________________ *MUNICIPALITY NAME/TITLE OF GOVERNING SIGNATURE BODY REPRESENTATIVE William Sullivan _________________________ __________________________________ ____________________________ ALLIANCE CHAIRPERSON SIGNATURE DATE * If a municipality is part of a consortium, a signature and resolution is required from all participating municipalities entering into the agreement. Signatures hereby accept all components of this grant including membership terms, Statement of Assurances and Fiscal Requirements. FOR COUNTY USE ONLY Approved: ____ YES _____ NO Date: