1. Name of Network Member Institution:

2. Network Member LIBID:

3. Technology Meeting Coordinator:

4. Position/Title of Technology Meeting Coordinator:

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 $5,000.00 Please supply a brief budget.

Meal per diems are the only allowable food expenditure.

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

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

11. Federal Tax Id Number (FEIN):

12. Brief description of planned agenda or goals and objectives of the meeting planned. Include anticipated date and the location planned.

13. Expected audience - who will be invited, expected number of attendees.

14. Are exhibits planned? If so, who will be invited? What NLM presence will there be (exhibitor, system sessions planned?)

15. Other partners and their planned contribution.

to the SE/A office for review