You must be a DOCLINE member to apply for this funding.

1. Name of Network Member Institution:

2. Applicant's name:

3. Network Member LIBID:

4. Mailing Address:

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

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

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

8. Award funding is $200.00 in starter funds for non-participating EFTS members.

Hospital libraries currently participating in EFTS- $100.00 incentive fee.

Non-Participating EFTS member - $200.00

Hospital Library currently participating in EFTS - $100.00

9. Congressional District

10. DUNS Number

to the SE/A office for review