Local Chapter Grant Application

Local Chapter Name:*
Area Served:*
Local Chapter Contact
Full Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone:*

Area CodePhone Number
Fax:

Area CodePhone Number
E-mail:*
Event Information
Date of Event:*

MonthDayYear
Title of Event:*
Anticipated # of Attendees:*
Target Audience:*
(i.e., nurse, dietitian, patient, etc.)
Name and Affiliation of Speakers:*
Applying for CE/CME:*

YesNo
Has Bina George-Figueroa approved your program?

YesNo
Contact Information of Funder
Identified Funding Source:*

YesNo
Name:
Phone:
Email:
Amount Being Requested:*
Attach the following items to your application
File name should start with the Local Chapter Name (ie: CRNGreaterNY_NeedsAssessment.doc).
Needs Assessment*

Upload a File

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Full Program Description*

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Educational Goals & Objectives*

Upload a File

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Preliminary Meeting Agenda (topics and times)*

Upload a File

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Full Line Item Budget*

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List of Faculty (includes name, organization, title and email address), or Faculty Resumes*

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Should be Empty: