Name of Network Member Institution

Network Member LIBID

FEIN (Taxpayer ID#)

Project Manager(s)

Mailing Address

Internet E-mail Address (e.g., maryc@project.org)

Telephone number (e.g., 555-555-5555)

Fax number (e.g., 555-555-5555)

Name of activity

Date(s) and location of activity

Describe target population or audience for this activity.

Provide the rationale for what benefits will be derived by the target population from your activity.

Provide your rationale for selecting this activity, including why it is appropriate to the NN/LM outreach mission

Provide a list of the key personnel for the project and describe each person's responsibilities. Please send resume or curriculum vitae for key personnel via email, mail, or fax.

Provide a budget for your activity. Examples of allowable expenses include publicity, honoraria and travel, professional services (writing, editing), consultant costs, room rental, equipment rental, printing/reproduction/graphics, other materials/supplies (specify).

Total amount requested (maximum $1000)

Explain how you plan to evaluate the success of your activity.

to the MAR office for review