MACOMB COUNTY COMMUNITY MENTAL HEALTH SERVICES

REQUEST FOR PROPOSAL COVER SHEET

Title:_________________________________________________________________________

         _________________________________________________________________________

         _________________________________________________________________________
						
(Please specify which RFP you are responding to)

Submitted by:

	1. Name of Organization____________________________________________________

	    ____________________________________________________________________  

	2. Address_______________________________________________________________

		     _______________________________________________________________

	3. Phone_________________________________________________________________

	4. Fax # _________________________________________________________________

	5. Email  ________________________________________________________________

	6. Name of Contact Person _________________________________________________

	    Title _________________________________________________________________

	    Phone ________________________________________________________________		

______________________________________________________________________________
(Agency Authorization Signature)                                                            (Date)