1. Name of Network Member Institution:

2. Network Member LIBID:

3. Proposed Trainer:

4. Position/Title of Proposed Trainer:

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 $600.00 Please supply a brief budget.

Funding will cover costs for travel (per diems, hotel, transport, etc) reproduction, communication and equipment or room rental, if needed.

No course development or indirect costs are allowed for this award.

10. How will you spend the award?
Provide a cost break down and 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. Describe target population or audience for training.

13. Outline of training, number and location of session.

14. Plans for evaluation of training, instruction.

15. Plans for follow-up with trainees and/or partner organization(s):

to the SE/A office for review