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Online Grant Application Process
Submit this Grant Application Form online to initiate a grant review for funding consideration by the Community Pharmacy Foundation.
1. Date Submitted   August 20, 2008
2. Amount Requested (digits only, no commas please)$
3. For What Time Period (digits only, no commas please)  Months

GRANT CLASSIFICATION

4. Of The Following Classifications Which One Most Reflects The Focus Of The Program/Project For Which You Are Requesting Grant Support -
  Directed Study/Research* Organizational Advancement/Development
  Practice Demonstration Practice Advancement (emphasis on technology)
  Project Development Residency/Fellowship Development
  Other (describe)  
  * Includes data analysis, policy analysis, practice or patient survey, etc
5. Program/Project Title
6. Brief Description Of The Objectives For This Program/Project (5 - 7 sentences)

PERSONAL CONTACT INFORMATION

7. Name of Person Submitting This Application
8. Telephone No.
(area code first)		 9. Email Addr.
10. Mailing Address
11. City 12. State/Province
13. Zip 14. Country (if other than USA)
15. Fax No.
(area code first)
16. Relationship To Organization Requesting Grant

ORGANIZATION CONTACT INFORMATION

17. Organization/Pharmacy/College Name
18. Mailing Address
19. City 20. State/Province
21. Zip 22. Country (if other than USA)
23. Fax No.
(area code first)
24. Executive/Owner/Dean/Principal Name
25. Telephone No.
(area code first)		 26. Email Addr.
27. This organization is a (designate one) For Profit Entity Non Profit Entity
  27.1. If Non Profit, Designate Its Tax-exempt Classification [i.e. 401(c)3]

PROGRAM/PROJECT INFORMATION

28. Is This A Start-Up or New Program/Project Yes   No  
  28.1. If "Yes," Is It Anticipated This Program/Project Will Be Completed In Total If This Grant Request is Awarded Yes   No  
  28.1a. If "YES," Will It Be On-Going And Self-sustaining Yes   No  
  28.2. If NOT A Start-Up, Were Other Funding Sources Provided For Start-Up Yes   No  
  28.2a. If "YES," What Were The Other Funding Sources And The Approximate Funds Provided By Each
 
29. Will Your Organization Provide Matching Funds If Such Is A Stipulation For Awarding A Grant For This Program/Project Yes   No  
30. Does this Program/Project Involve Collaboration With Another Health Profession Or Health Professional Organization Yes   No  
31. Has The Principal Or Coordinator Of This Grant Request Had His/Her Work Published In A Peer Reviewed Publication Yes   No  
32. Has This Program/Project Been Previously Submitted To CPF
For Funding Support		 Yes   No  
33. List The Top 4 Anticipated Expenditures As A Percentage Of Total Budget (i.e. salaries – 30%; marketing – 20%; equipment – 10%, postage & supplies – 10%)
34. How did you find out about the Community Pharmacy Foundation?
  CPF Website Link From Other Website
  Professional Meeting Colleague
  eNews
  Other (describe)  
35. Other Comments (2-3 Sentences)

 
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