The New Mexico Breastfeeding Task Force Grant Application Cover Sheet Name of Local Task Force: _______________________________________________ Project Title: __________________________________________________________ Address: _____________________________________________________________ Contact Name: _________________________________________________________ Address: _____________________________________________________________ Phone/Fax: __________________________ ________________________________ E-mail: _______________________________________________________________ Please provide a brief synopsis of your project. A few sentences are sufficient. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Total Grant Amount Requested: _____________________________________________ Check Should Be Made Out To: _____________________________________________ ____________________________ ____________ ___________________________ Signature of Grant Coordinator Date Print or Type Name ____________________________ ____________ ___________________________ Signature of Local Task Force Chair Date Print or Type Name Submit applications to: Grant Committee Contact: Jacie Coryell, Grant Coordinator Jacie Coryell 8801 Lagrima del Oro NE 8801 Lagrima de Oro NE Albuquerque, NM 87111 Albuqueque, NM 87111 jacie@swcp.com 505-293-5215 jacie@swcp.com |