Date: ______________________

Name:______________________________________________________________

Address: ____________________________________________________________

Email: _______________________________________________________________

Organization name: _________________________________________________________

Address:______________________________________________________________________

Website:_________________________________ Contact Person_____________________

1.  Please describe your role with the organization:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2.  Please describe the public health project you are raising funds for: 

___________________________________________________________________________________________________________________________________

3. How would you like HPGF to assist?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Please explain any previous projects or community service you participated in and the results:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Is there anything you would like to add?

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HPGF may make this need known to others so that they have the opportunity to contribute. The office may contact you for more information and clarity. If you do not get a response from HPGF in two weeks, please feel free to re-contact us.  

I certify the information provided is accurate to the best of my knowledge and understand and that falsification may result in appropriate penalties. 

Signature___________________________________________ Full Name: ____________________________________ Date:____________

Please send this application to JNCMissions@gmail.com, along with a head and shoulders picture for identification, which may be used in publication.  In the subject line put “Project Request.”