1. Name of Network Member Institution:

2. Network Member LIBID:

3. Network Member Name:

4. Position/Title of Project Manager:

5. Department:

6. Mailing Address

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

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

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

10. Award funding is a maximum of $5,000.00 Please supply a brief budget.

Funding will cover personnel, communication, equipment, supplies, reproduction, and travel.

No additional food costs are allowed.

No indirect costs are allowed.

How will you spend the award? (Provide a cost breakdown with a justification for each budget line.)

11. Award should be made payable to what institution (i.e., Southeastern Regional Medical Center)?

12. Federal Tax Id Number (FEIN):

13. Proposed start date for 12 month project (e.g. July 1, 2008):

14. Project Title:

15. Provide a summary statement of the proposed project or study:

16. Describe the institutional environment and current role/status of the library and library staff:

17. Identify the project objectives and desired outcomes:

18. How will you measure your outcomes?

19. List any institutional support that will be provided.

20. With which individuals or departments will you work? In what ways will they participate?

21. How will you promote/publicize the project and report your findings?

to the SE/A office for review