APPLICATION FOR OVERSEAS GRANT

Applicant Information:

Name and Title:

Organization:

Address:

Email Address:

Telephone #:

Project Information:

Title of Project:

Background and Purpose of Project:

(Give concise description of problems, goals and purposes that this project will address)

Targeted Populations:

Project Location: Village, Town, District, State or Province, Country

Period of Time:

Schedule of Activities:

How Will Project Be Conducted?

Expected Outcome: (Give brief description of expected outcome of the project)

Dissemination: (Briefly explain how the outcome of the project will be disseminated: publication, media coverage, conference)

Funding Needed: (Specifically describe purpose of funding)

Dollar Amount:

Report on Results of Project Must Be Submitted To OMPACO Board no later than 2 months after return from Project. In addition, photographs taken during project may become a part of Ompaco Website and can be used in OMPACO presentations.

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Applicant Signature Date