Awards and Grants Program of The Maxillofacial Foundation

Application for Support

The applicant or representative of the organization or agency requesting funds should complete this application to the best of his/her ability. All questions should be completed in detail.

Research Study:

Technical Procedure:

Educational/Professional Meeting:

Special Project:

Applicant (individual/organization):

First Name:

Last Name:

Mailing Address:

City:

State:

Zip:

Telephone:

Email:

Fax:

Project Title:

Proposed Support Period (Dates):

Total Cost of Project:

Amount Requested:

Has the proposal been submitted previously to any agency?
Yes No

Date Submitted:

Outcome:

Is other external support being sought for this application?
Yes No

If yes, from where?

Date submitted:

When will outcome be known?

If a Research Study, does the proposed project involve Human Subjects?
Yes No

If yes, please attach a letter of approval by Human Subjects Review.

Summary of Proposed Budget:

Salaries and Wages:

Overhead:

Supplies and Materials:

Equipment:

Other (Itemize):

Please provide a detailed justification for the Proposed Budget:

If this application is for supplemental funding, please explain the other source(s) of funding. Specifically what portions of the budget are to be covered by the funds from the Maxillofacial Foundation.