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Instructions: The information requested in this form will help us understand the status and nature of your project so that we can provide assistance appropriate to your situation. Rather than being an exercise, the information you supply will provide the basis for conducting prospect research and in creating a concept paper, which is the first step in seeking a grant. As this is a preliminary concept document, please do not be overly concerned with accuracy or the need for future modifications.
Fill in as many fields as you can. (Required fields are marked with an asterisk: *) For longer answers, it may be easier to compose the entry in a word processor and then copy and paste the answer into the form. Note: formatting (lists, bullets, fonts, etc.) will not be copied.
For questions, please contact
Joan Rubio, Senior Director, Central Development, at
Project Director or PI
Campus Extension or Phone #
College / Program
Project or period start date:
How many months or years?
(please include unit of measure: months or years)
Estimated Total Project Cost
(entire amount for duration of the project)
Date Funds Needed
Brief Project Summary (600 words; about 1 page):
include problem statement, goals & objectives, approach or methodology, target population, service goal (number to be served), evaluation or assessment, and qualification of project staff, dept. and college.
If you are able, provide general breakdown of project budget. List major expense categories, i.e., staffing $25,000, equipment $10,000, materials & supplies $2,000, travel $2,000, facility rent $500, etc.:
If a continuing program, list funders and amounts for previous 1-3 years:
Total amount raised to date (cash and pledges), if any, toward project:
List donor names and amounts pledged or received (if numerous, list largest donors):
List any pending proposals or prospects and requested amounts, if any:
Amount still needed to complete the project:
Unfortunately, some automated programs are using forms to generate "SPAM." To prevent this practice we ask that you answer the question below. When you enter the correct response it ensures that the message is coming from a real person.
What is the sum of three plus 1?
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