Innovation Fund Application Form by 55q3aEg

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									                            INNOVATION FUND APPLICATION FORM

Sponsor: NB Department of Health, Chronic Disease Prevention & Management Unit

Section A:         PROJECT LEAD INFORMATION & PROJECT NAME

  Project Lead(s) Name:

  ______________________________________________________________________________

  Project Lead(s) Signature:

  ______________________________________________________________________________

  Designation/Department/Institution/Organization:

  ____________________________________________________________________________

  Contact Information:

  ____________________________________________________________________________

  Project Name:




If the project is selected for funding, a letter of support from the appropriate Manager or
   T
Organizational Director will be required prior to fund distribution.


                   All applications must be submitted by August 17th, 2012, via mail to:

                                               Innovation Fund
                              NB Chronic Disease Prevention & Management Unit
                             Primary Health care Branch, NB Department of Health
                                          HSBC Building, 2nd Floor
                                                520 King Street
                                                 P.O. Box 5100
                                               Fredericton, NB
                                                   E3B 5G8



The information collected in this Application Form is for the purposes of funding evaluation and will be shared with the
evaluating team. A summary of the funded projects will be hosted, along with the name and contact information of the Project
Lead, on the GNB website for knowledge sharing. The applications for funding will be retained for the duration of the
Innovation Fund initiative. If you have further questions please contact the Department of Health, Primary Health Care Branch
by phone at 506.444.4174 or by email at DiabetesStrategy.StategieDiabete@gnb.ca .
Section B:         Please refer to the Innovation Fund Guidelines when completing this
                   application form. The following information is consistent with the Project
                   Assessment Criteria outlined in the Innovation Fund Guidelines.
                   (Please use extra paper as necessary)


    i. PROJECT DESCRIPTION




The information collected in this Application Form is for the purposes of funding evaluation and will be shared with the
evaluating team. A summary of the funded projects will be hosted, along with the name and contact information of the Project
Lead, on the GNB website for knowledge sharing. The applications for funding will be retained for the duration of the
Innovation Fund initiative. If you have further questions please contact the Department of Health, Primary Health Care Branch
by phone at 506.444.4174 or by email at DiabetesStrategy.StategieDiabete@gnb.ca .
    ii. PROJECT IMPLEMENTATION PLAN




The information collected in this Application Form is for the purposes of funding evaluation and will be shared with the
evaluating team. A summary of the funded projects will be hosted, along with the name and contact information of the Project
Lead, on the GNB website for knowledge sharing. The applications for funding will be retained for the duration of the
Innovation Fund initiative. If you have further questions please contact the Department of Health, Primary Health Care Branch
by phone at 506.444.4174 or by email at DiabetesStrategy.StategieDiabete@gnb.ca .
    iii. PROJECT DELIVERABLES




The information collected in this Application Form is for the purposes of funding evaluation and will be shared with the
evaluating team. A summary of the funded projects will be hosted, along with the name and contact information of the Project
Lead, on the GNB website for knowledge sharing. The applications for funding will be retained for the duration of the
Innovation Fund initiative. If you have further questions please contact the Department of Health, Primary Health Care Branch
by phone at 506.444.4174 or by email at DiabetesStrategy.StategieDiabete@gnb.ca .

								
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