ACADEMICENGAGEMENT Email Marketing -

I certify that I have reviewed the micro-grant requirements detailed above and that the initiative for which I am requesting a micro-grant does, and will continue to, comply with all such requirements. I further certify that my initiative will not be

Agree

APPLICANT INFORMATION

First Name*

Last Name*

Email*

Contact Number*

Institution*

Department or Unit*

Sponsoring Department*

Department Contact Person*

Department Contact Number *

INITIATIVE PROPOSAL

Initiative Title*

Date of Event*

Describe the desired outcomes of your initiative.*

In a few sentences, describe how you hope to achieve your goals and make the initiative successful.*

Please list any organizational co-sponsors of this initiative, if applicable.*

FUNDING INFORMATION

Amount Requested*

How will the funds be used (e.g., honorarium, travel expenses, etc.)? Please be as specific as possible in your projected breakdown.*

Mailing Address

Street Address*

Address Line 2

City*

State / Province / Region*

Postal / Zip Code*

Country*