Converse County Foundation Grant Application

Date

Address

First

Last

Address

City

State

Zip

Phone Number

Organization

Department

Equipment / Project

Cost of Equipment / Project

Additional expected associated costs

E.g., construction, annual fees/maintenance, supplemental equipment, etc.

Description of request, to include:

Why is this equipment/project needed?
How many patients/staff/providers will this equipment/project benefit and how?
Who is in support of this request (e.g., providers, staff, departments, capital project team)?

Description of request