Webform SOUTHEAST COALITION FOR ROADWAY SAFETY FY2022 Application for Law Enforcement Funding (July 2021 – June 2022) For consideration, please submit your application no later than June 15, 2021. Contact Name* Agency* Phone Number* Email Address* Address Address* City/Town* State/Province* - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code* Please enter the requested equipment below. Please enter information for one or more items for your request. Please provide complete information (item description/name, quantity and cost) for each different item included in your request. Item Description* Quantity* Unit Cost* Item Description Quantity Unit Cost Item Description Quantity Unit Cost Item Description Quantity Unit Cost Item Description Quantity Unit Cost Total Cost of Items Requested* Additional Information Please provide justification for how the equipment will help reduce the number of fatalities and/or serious injuries.* Upload an attachment for additional justification. One file only.352 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, pdf, avi, mov, mp4, svg, tar, zip.