February 12, 2004 - DOC

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					                                            The Wellmark Foundation
              2012 Healthy Communities Grant Program ($20,000 and under)
                     Letter of Interest Cover Page – Due Date August 14, 2012
        ________________________________________________________________________
                  Primary Agency/Fiscal Agent – Organizational Information
 (If this is a collaborative/coalition project, then please submit names of collaborating organizations on a separate sheet.)
Name:__________________________________________________________________________________

Address: ________________________________________________________________________________

City/State/Zip:____________________________________ Phone: _________________________________

Web site: ________________________________Geographic focus/county: __________________________

IRS 501(c)3 Determination Number or EIN Number: ___________________________________________
____________________________________________________________________________________
Primary Proposal Contact Person
Name: __________________________________________________________________________________

Title: ____________________________________ Organization: ___________________________________

Address: ____________________________________City/State/Zip:________________________________

Phone: _____________________________________ Email: ______________________________________
_______________________________________________________________________________________
Project Information
Project Title: _____________________________________________________________________________

Total Project Budget: $ __________________ Project Duration (not to exceed 24 months): _________months

Amount Requested (not to exceed $20,000 or 75% of total project budget): $ ________________________

Check Priority Funding Area: Childhood Obesity Prevention Wellness and Prevention Initiatives
________________________________________________________________________________________
Brief paragraph (2 to 3 sentences) summarizing the project.




______________________________________________________________________________________
Authorization (required to demonstrate knowledge of and support for the proposed project)
_________________________________________                            ___________________________________________
President, Board of Directors (Chief Volunteer)                      Executive Director (Chief Compensated Staff)*

________________________________________                             ___________________________________________
Print Name, Title and date                                           Print Name, Title and date
*If no compensated staff, provide signature of another member/officer of the Board of Directors

				
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