PADESTA with PSOA Grant Application
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Complete both Sides
Applicant (contact person):_____________________________________________________ Address: ____________________________________________________________________ Telephone-Work:____________________________ Home:___________________________ Project Title:_________________________________________________________________ ____________________________________________________________________________ Project Description: Description of how the project furthers and promotes ASTA with NSOA ideals: Starting Date: __________________________ Completion Date:_______________________ Site of Project:________________________________________________________________ Intended Participants:__________________________________________________________ If applicable, clinician name and amount of honorarium:__________________________________________________________________ Projected Budget (list all anticipated expenses and all sources of expected revenue, including other grants, grants in kind and fees charged). ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ Total Funds Requested:________________________________________________________
By signing this agreement, the applicant agrees to abide by all the rules stated above. Signature:__________________________________________Date:_____________________ Please include a photocopy your membership card to this application |