1. Name of Network Member Institution:

2. Network Member LIBID:

3. Award/Library Manager:

4. Position/Title of 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. Brief description of why organization needs assistance.

11. Award is for a maximum of $5000.00

• Funding will cover computer equipment, computer or library supplies, printer, fax, scanner, high speed internet service, subscription cost, print texts (cannot exceed 10% of direct costs), and document delivery fees of up to $500.
• No personnel or indirect costs are allowed.

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

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

14. Federal Tax Id Number (FEIN):

15. How will you promote your restored services?

to the SE/A office for review