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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 __________ ~~~~~~~~~~ The New Mexico Breastfeeding Task Force Grant Application Budget Form Description of Proposed Itemized Expense Actual Expense due Expense November 15, 2007 1. ___________________________________________________________ 2. ___________________________________________________________ 3. ___________________________________________________________ 4. ___________________________________________________________ 5. ___________________________________________________________ 6. ___________________________________________________________ 7. ___________________________________________________________ 8. ___________________________________________________________ 9. ___________________________________________________________ 10. ___________________________________________________________ 11. ___________________________________________________________ Total Expenses __________________ __________________ Money should only be used for expenses specified in the grant unless approved by the NM Breastfeeding Task Force Grant Committee. Extensions for completion of the grant may also be requested from the Grant Committee. Final Accounting will be submitted, for actual expenses between January 15 and September 30, 2007, by November 15, 2007. __________________________________ ___________ ________________ Print or Type Name Date __________________________________ Signed by Grant Coordinator Or other Fiscal Agent |
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