GOVERNMENT OF 
THE UNITED STATES VIRGIN ISLANDS 
THE OFFICE OF MANAGEMENT AND BUDGET 
 
                                                                                 No. 5041 Norre Gade 
                                                          Emancipation Gardens Station, 2nd Floor                                         
          Charlotte Amalie, U.S. Virgin Islands 00802 
       Telephone: (340) 774-0750 
 
 
 
Section 1: Applicant Information 
 
Organization Name:  
_________________________________________ 
 
Authorized Representative: 
 
Name: ____________________________________ 
 
Title: _____________________________________ 
 
Business Address: 
Street: ____________________________________ 
 
City: ____________ State: ____ ZIP: ________ 
 
Email Address: _______________________________ 
 
Phone Number: _______________________________ 
 
Website (if applicable): _________________________ 
 
DUNS/UEI Number: ___________________________ 
 
Federal EIN (Tax ID): __________________________ 
 
Section 2: Eligibility Information 
Organization Type: 
☐ Nonprofit 
☐ For-Profit 
☐ Tribal Government 
☐ State/Local Government 
☐ Public-Private Partnership 
☐ Other (please specify): _______________ 
 
Is your organization currently registered in SAM.gov? 
☐ Yes ☐ No 
(If yes, please provide CAGE Code: ____________) 
 
Have you previously received federal funding for broadband deployment or related 
services? 
☐ Yes ☐ No 
If yes, please describe: 
 
Section 3: Project Proposal Overview 
 
Project Title: ______________________________ 
 
Brief Project Summary: 
(Please summarize your proposed project in 200–300 words) 
 
Project Location(s): 
List geographic area(s), counties, or census blocks to be served. 
 
Proposed Service Area Type: 
☐ Unserved 
☐ Underserved 
☐ Community Anchor Institutions 
☐ Other: ____________________________ 
 
Section 4: Project Details 
Total Funding Requested: 
$__________________ 
 
Total Project Cost: 
$__________________ 
(Please include any match or leveraged funds) 
 
Matching Funds Source(s) and Amounts (if applicable): 
 
Project Start Date: ______________________________________ 
 
Estimated Completion Date: ______________________________ 
 
Technologies to be Deployed: _____________________________ 
 
 
Section 5: Impact and Outcomes: 
 
Estimated Anchor Institutions Served: ________________________ 
 
Workforce Development Components: ________________________ 
 
Digital Equity & Inclusion Activities: _________________________ 
 
Section 6: Required Attachments: 
Please include the following documents with your application: 
 
☐ Detailed Project Narrative 
 
☐ Project Budget 
 
☐ Timeline & Milestones 
 
☐ Maps of Service Area 
 
☐ Letters of Support (if applicable) 
 
☐ Organizational Chart & Key Personnel Bios 
 
☐ Evidence of Matching Funds (if required) 
 
☐ SAM.gov Registration Confirmation 
 
 
 
 
 
 
Section 7: Certifications: 
 
I hereby certify that all information provided in this application is true and complete 
to the best of my knowledge. I understand that any false statements may disqualify 
this application. 
 
Authorized Signature: 
 
Printed Name: 
 
Date: