nriAHEC: Grant Application

Northern
Rhode Island
Area Health
Education Center

1 Cumberland Plaza,
(Blockbuster Building)
2nd Floor
Woonsocket, RI 02895

Tel: 401.356.4077
Fax: 401.356.4269

Executive Director
Program Manager
General Information

Grant Application

Name:
Org / School:
EIN:
Address:
Town/city:
State:		Zipcode:
Phone: (xxx-xxxx)		Fax: (xxx-xxxx)
Email:
Contact Person:
Total Project Budget:
Grant Request: ($)		Period Grant Will Cover:
Project Title:

Brief description of Organization's mission or Individual's Background

Summary of proposed project or grant request

Clearly explain expected outcomes of this project and how they align with AHEC's program objectives

Project Budget

Please be aware that the monies awarded to you from nriAHEC are not to be used toward the cost of meals and/or honorarium(s). Receipts for any and all purchases made with these funds are to be submitted to nriAHEC along with the reports.

Project Expenses (list below)	Request	In-Kind





Total Project Expenses