Indicate in which division the project will be implemented.
See the March of Dimes 2013 Request for Proposals Application Guidelines (RFP) page 5 for a list of division counties.1 Central New York 1 Genesee Valley/Finger Lakes 1 Long Island 1 New York City
1 Northeastern New York 1 Northern Metro 1 Staten Island 1 Western New York
* ALL SECTIONS MUST BE COMPLETED for proposal to be considered *
1. Applicant Organization
2. Project Title
3. Project Site and Address (if different from organization)
4. Organization Address
5. Contact Name
6. Phone/Fax
7. E-mail
8. Web Site
9. Please provide a brief synopsis of your project (2 sentences are sufficient): To provide
.
10. Approximately how many unduplicated individuals will be served during the grant year?
11. List the race/ethnicity of the majority of individuals served (if applicable):
12. Please indicate the positive impact that the project will measure and report on:
[ ] Increase in knowledge [ ] Behavior change [ ] Improved birth outcomes
[ ] Other
13. Please list the one primary funding priority that the application addresses from the numbered
funding priority areas on page 2 of the RFP:
14. Total amount requested: $ Cost per individual: $
15. Check should be made out to: ______
16. Is your agency willing to accept partial funding? [ ]Yes [ ]No
17. Does the budget include funds for a consultant or other subcontract? [ ]Yes [ ]No
______/___/______
Signature - Primary Staff Person Date Type Name and Title
______/___/______
Signature - Executive Director Date Type Name and Title
February 2012