1. Name of Network Member Institution:

2. Network Member LIBID:

3. Project Manager:

4. Position/Title of Project Manager:

5. Department:

6. Mailing Address

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

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

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

10. Award funding is a maximum of $3,500.00 Please supply a brief budget.

Meal per diems are the only allowable food expenditure. No indirect costs are allowed.

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. Proposed start date for 12 month project (e.g. July 1, 2006):

14. List your project objectives.

15. Describe how you will complete the project objectives (your project plan).

16. List any institutional support that will be provided.

17. How will you promote your project to the target audience?

18. How will you evaluate your project's effect?

19. What are the plans to sustain the project?

to the SE/A office for review