Agency Name:

Contact Person:

Title:

Phone:

Email:

Fax:

Name of Project/Proposal:

1.  Briefly summarize the project/proposal.  How does it meet the purpose and goals of the HSCC?  Does it meet an unmet need in Bay County?  If it is an existing program or service, does it serve an identified need in Bay County?

2.  Describe the services or acquisitions planned in the proposal.  Is the project a duplication of existing services?  If so, is there a documented need for it?

3.  Describe your organization's relationship with the HSCC.  How will the project continue or develop a relationship with the HSCC?

4.  How does the project cooperate, coordinate, and/or collaborate with other related programs and services?

5.  Total Amount of Request:

6. Total Cost of Program:

7.  What is the estimated percentage of funding that represents services to Bay County?

8.  What is the timeline of the funding being sought?

9.  What are the plans for the continuation of the program after the funding expires?

10.  Type of grant source:

11.  Name of Grant Source: