Appendix 15 – Letter of Intent

MOVING CALIFORNIA ORAL HEALTH FORWARD 2022-2027

Local Oral Health Programs

Please complete the following and email this document to DentalDirector@cdph.ca.gov no later than November 5, 2021.

Local Health Jurisdiction: Click or tap here to enter text.

Project Director or Designee: Click or tap here to enter text.

Email: Click or tap here to enter text.

Phone: Click or tap here to enter text. Fax: Click or tap here to enter text.

Yes. We intend to apply for the funds from the California Department of Public Health, Office of Oral Health (CDPH/OOH), to continue or implement the Local Oral Health Program for my Local Health Jurisdiction (LHJ).	Check Box 4
Yes. We intend to apply for funding from CDPH/OOH to implement the Local Oral Health Program and will likely pursue a consortium with the following LHJ(s).	Check Box 1
No. We do not intend on applying for this opportunity to implement a Local Oral Health Program for our LHJ.

Please select one response:

Please complete the fields below:

Does your LHJ require a board resolution for a new contract?	YES NO
When are your scheduled board meeting dates between November and January 2022?
Does your LHJ require the contract be available to get on the Agenda?	YES NO
When do you need the contract? (e.g., two weeks before, one month before, etc.)

Please note: This letter of intent is expected but not considered binding. If you cannot complete by the deadline, please email DentalDirector@cdph.ca.gov.

Click or tap here to enter text.	Click or tap to enter a date.

___________________________________	____________________

Signature of Project Director or Date

Designee