Provide the following information in this order. For your convenience, you may choose either to copy and fill out this cover summary or create your own using the headings listed below.

Title of Proposal: ______________________________________________________

Requestor: ___________________________________________________________

Phone Number: __________________ FAX Number: ________________________

E-Mail ______________________________________________________________

Name of Co-Requestor: _________________________________________________

Phone Number: __________________ FAX Number: ________________________

E-Mail ______________________________________________________________

Name of Organization to which grant would be paid. Please list exact legal name:

____________________________________________________________________

Address of Organization:

____________________________________________________________________

Total Proposed Project/Program Budget: _____________________________

Amount Requested: ______________________

Duration of Project/Program: Start Date: _____________ End Date: ______________

The undersigned does hereby certify that the information set forth in this grant application is true and correct. I agree to accept responsibility for the conduct of the project and to provide the required project reports if an award is made as a result of this application.

Requestors Signature: ________________________________________________

Print Name/Title: _____________________________________________________

Date: ________________________

Co-Requestors Signature: _____________________________________________

Print Name/Title: _____________________________________________________

Date: ________________________

An officer of the organizations governing body must sign this application:

The undersigned, an authorized officer of the organization, does hereby certify that the information set forth in this grant application is true and correct. I agree to accept responsibility for the conduct of the project and to provide the required project reports if an award is made as a result of this application.

Authorized Officer Signature: ___________________________________________

Print Name/Title: ____________________________________________________

Date: ________________________

Grant Application
Page 2

GENERAL INSTRUCTIONS AND INFORMATION

• Type and single space all proposals (12 point font)
• Provide all of the information in the order listed
• All questions must be completed fully
• Submit ten copies of the application with numbered pages
• Do not send videotapes
• This Grant Application form is to be used for all types of proposals. We retain the option to require additional information from applicants.
• The Whippet Health Foundation, Inc. shall be entitled to 10% of the Net Revenues of any invention resulting from a study they fund

Submit Grant Applications to the following address:



NARRATIVE
PLEASE PROVIDE THE FOLLOWING INFORMATION IN THE ORDER PRESENTED BELOW.

(No more than ten narrative pages, plus no more than one page of references; twelve point font; one inch borders; include applicants name on the top of each page.)

1. Complete Project Description
    • Describe the importance of the proposed research and relevance to the Foundations mission statement
      and interests
    • Description of project goals and measurable objectives
    • Need for the project and how the need was determined
    • Expected outcomes
    • Plans and timetables for implementation
    • Staffing requirements
    • Means for evaluating the projects results
    • Projects actual or projected expenditures and revenues for the project period
   
2. Budget
    • Budget should include detailed breakdown of all items and estimated cost to the Foundation.
    • The Foundation does not pay for administrative overhead.
    • Be brief but as accurate as possible, showing budget figures for each year, if multi-year.
3. Duration of project. All projects are subject to yearly review.
4. Explain how you plan to evaluate the project.
5. Is this request part of a larger ongoing program? Include previous and proposed funding by all sources.