|
| Briefly
describe the project or activity: |
| _______________________________________________________________________ |
|
| _______________________________________________________________________ |
| _______________________________________________________________________ |
| _______________________________________________________________________ |
| _______________________________________________________________________
Include the location, involved
organizations, expected benefit or outcome. |
|
| Describe
the individual or group who will benefit by name, position, or in the
case of students, the number, their grade and/or particular
circumstances: |
| ______________________________________________________________________ |
| ______________________________________________________________________ |
| ______________________________________________________________________ |
| What
amount are you requesting? __________ Date funds are needed:
____________ |
| What
are the total expenses for the activity/project? _____________ |
| What is/are the
date(s) of the activity/project? _________________________________ |
| Applicant
Name: _____________________________
Phone:____________________ |
| Address:
_______________________________________________________________ |
| Signatures: |
__________________
Applicant |
____________________
Administrator/Supervisor |
____________________
EPIC Representative |