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GRANT REQUEST
Project Title
Applicant Name
Primary Contact (name/title)
Street
City
State
Zip
Phone
Email (Required)
Company #
Cost Center #
Fund #
Sub-Fund #
Amount Requested *
Description of Request
1. Project Description (include timeline and project goals)
2. How does this project match the mission of CREFI?
3. Does your project need licensing, clearances and/or contacts? If so, explain.
4. How does your project affect quality of care?
5. Describe the potential impact of the project and who will benefit.
6. What are the intended outcomes of the proect and how will they be measured?
7. What is the financial sustainability of your project/program? (If successful, how will the project financially support itself when grant dollars are expended?)
Please attach project budget including total costs and indicate any other sources of income as well as any other budget considerations.