1. Name of Network Member Institution:

2. Network Member LIBID:

3. Project Manager:

4. Position/Title of Project Manager:

5. Mailing Address

6. Internet E-mail Address (e.g., maryc@project.org):

7. Telephone number (e.g., 555-555-5555):

8. Fax number (e.g., 555-555-5555):

9. Award funding is a maximum of $5,000.00 Please supply a brief budget.

10. How will you spend the award? (Provide a cost breakdown with a justification for each budget line.)

11. Award should be made payable to what institution (i.e., Southeastern Regional Medical Center)?

12. Federal Tax Id Number (FEIN):

13. Congressional District

14. DUNS Number

15. Project Title:

16. Project Summary (250 words or less):

17. List your project objectives.

18. Describe target population or audience.
Example: Senior Citizens, Public Health Nurses, Health Educators

19. Describe how you will complete the project objectives.

20. Explain how you will evaluate the project and describe how you will measure the success for each objective.

21. List project personnel, their role in this project and experience relevant to this project.

22. Name, address and description of partner organization(s).

23. Provide any additional supporting information about your proposed project.

to the SE/A office for review