1. Name of Network Member Institution:

2. Network Member LIBID:

3. Exhibit Lead:

4. Position/Title of Exhibit Lead:

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 $2000.00 Please supply a brief budget.

• Funding will cover registration and booth fees, travel and per diems, communication costs, publicity, promotional items, and equipment rental if needed. Provide an explanation for other costs needed not listed above.
• No additional food costs are allowed.
• No indirect costs are allowed for this award.

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

11. Federal Tax Id Number (FEIN):

12. Name of meetings or sponsoring organization; date and location of exhibit.

13. Expected audience (e.g., "Public health professionals in Florida. Average annual meeting attendance is 400.")

14. Describe physical exhibit, handouts, and any special focus or theme.

15. Please give the names of the expected booth staff.

16. Other participation in this meeting? Will you give a talk, teach a workshop, or network in some other way?

to the SE/A office for review