Grant Proposal Application

*Required Fields

Date of Health Screen: (mm/dd/yyyy)*  

Date of Operating Plan: (mm/dd/yyyy)*  

Date of Last Behavior Change Program: (mm/dd/yyyy)*  

Name of Last Behavior Change Program:*  

Worksite Name:*  

Worksite ID Number:

Worksite Coordinator Name:*  

Mailing Address:*  

                                

City:*      State:*      Zip:*    

County:*  

Telephone Number:*    

Fax Number:  

E-mail:  

Health Promotion Consultant:*  

Grant History:     New Applicant           Previous Grantee

Mission / Title / Description:*  

Detailed Budget:*   
For each item requested include full item name, model number and cost of item, including tax and shipping and handling if applicable.  Include Grand Total for all items.

Rationale:*  

Goal(s) and Objectives (Expected Outcomes):*  

Total Amount Requested:*     $ (Should Equal Budget Grand Total)

Purchased From: (Checks will be made out to worksite.) *  
List company name, mailing address, telephone number, and which item(s) is/are being purchased.

Mail Check(s) To:  (Worksite Name, Address) *  

Worksite Size (Total Number of Employees):*    

Estimated Number of Individuals Impacted by the Proposal:*    

Do you have an Evaluation Tool? *  
Please explain. This is REQUIRED. A copy of evaluation tool MUST BE submitted within same time of grant submission. Fax to (304) 345-2009.