Request for Funding from the Grant Program

(please type answers, print, and mail or fax this form)

Agency Name:

Address:

City:

State: Zip:

Telephone Number:
( )

Fax:
( )

Director:

Number of Employees:

Days of Operation:

Hours of Operation:

How long has your program been in existence?:

Type of Program:

Number of Alzheimer�s Participants in Program:

Reason for Request for Funding:

How will Funds be Used? (be specific):

Current Sources of Funding:

What are the Consequences/Contingencies if Funding is not Approved?:

Have you received a grant from the NOVA chapter in the past?

Yes

No

Will this Program Seek Funding on an Annual Basis?

Yes

No

Please itemize how grant funds will be spent::

Are you expecting other sources of funding to augment this grant request?

How would you acknowledge the Alzheimer�s Association funding of your program to the recipients, their families and/or the community? (i.e. letters to those who receive scholarships, newsletter article, etc.):

Signature: (please do not type; print and then sign in pen ink)

Date:

Send all information to:

ALZHEIMER�S ASSOCIATION
NORTHERN VIRGINIA CHAPTER
PATIENT AND FAMILY SERVICES COMMITTEE
10201 LEE HIGHWAY, SUITE 210
FAIRFAX, VIRGINIA 22030

(FAX) 703/359-4441

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Last updated: June 17, 1997

© 1997 & 1998 Alzheimer's Association, Northern Virginia Chapter. All rights reserved.

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