The New Mexico Breastfeeding Task Force Grant Application World Breastfeeding Week Stipends Name of Local Task Force: _____________________________ or Healthcare Agency:______________________________________ Check is to be made out to: _______________________________________________ Address where check is to be mailed: _____________________________________________________________ _____________________________________________________________ Phone/Fax: ___________________________________________________________ E-mail: _______________________________________________________________ Please provide a brief synopsis of your project and specifically list items to be purchased. A few sentences are sufficient. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ____________________________ ____________ ___________________________ Signature of Grant Applicant Date Print or Type Name Date Received by NMBFTF:_______________ ____________________________ ____________ ___________________________ Signature of Local Task Force Chair Date Print or Type Name Mail to: New Mexico Breastfeeding Task Force 430 LIve Oak Lane NE Albuquerque, NM 87122 Attn.: WBW Stipends |