The New Mexico Breastfeeding Task Force                                                                Grant Application                                              World Breastfeeding Week Stipends 1.  Name of Local Task Force: _____________________________ or Healthcare Agency:______________________________________ 2.  Check is to be made out to: _______________________________________________ 3.  Address where check is to be mailed:  _____________________________________________________________ _____________________________________________________________ 4.  Phone/Fax: ___________________________________________________________ 5.  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

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Mail to: New Mexico Breastfeeding Task Force 430 LIve Oak Lane NE Albuquerque, NM 87122 Attn.: WBW Stipends