Name and Address of the individual or Group:

Name:             _____________________________________________________

Address:        _____________________________________________________

                       _____________________________________________________

                       _____________________________________________________

Telephone Number: (        ) _____ - ________    Email: ___________________________________


A:      Has a detailed business or work plan been developed?     Yes____   No____

B:      If 'Yes", Please attach a copy; If  'No', please attach a statement of how you intend to proceed to
          accomplish  your goal. Your statement should include as much details as possible concerning
         costs, time frames, activities that will be undertaken in order to achieve your objectives.

C:      No funds will be advanced until the completion of your project, and only after this Board has
         reviewed the results. Therefore a complete financial report, with receipts, must be attached
         to your final submission.

D:      The amount to be reimbursed to you or to the Orgainzation shall be up to 50% of your net costs
          to a maximum of $ 250.00 per club or $200.00 per individual.



Signed:  ___________________________________________        Date:  ___________________


Attachments:  _________________________________________________________________
                         _________________________________________________________________
                         _________________________________________________________________