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 __________ ~~~~~~~~~~ Grant Application Budget Form Description of Proposed Itemized Expense Actual Expense due Expense November 15, 2012 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 must be submitted by November 15, 2012 for actual grant expenditures incurred up to September 30, 2012. __________________________________ ___________ ________________ Print or Type Name Date __________________________________ Signed by grant coordinator or other fiscal agent Submit applications to: Grant Committee Contact: Sharon Giles-Pullen Jacie Coryell WIC Nutrition Bureau 8801 Lagrima de Oro NE 2040 South Pacheco Albuquerque, NM 87111 Santa Fe, NM 87505 jacie@swcp.com 505-293-5215 sharon.giles-pullen@state.nm.us |