First name:

Last name:

Address:

Major and Year in School (if student) or Rank and Department (If faculty or staff)

Phone Number:

E-mail:

Please fill out with as completely as possible:

Expected starting and ending dates of the project (if relevant)
e.g. Fall 2006 - Spring 2007

Amount Requested:

Itemized Expenses, for example:

Hardware

1. Mitsubishi XL8U Projector - $2000.76

2. Toshiba Satellite M30 - $1,519.00

Software

1. End Notes - $250.99

2. Adobe Writer - $399.99

Brief description of the project that will be funded by this grant, including at statement as to how it will impact LSBE Students, Faculty and Staff

How will you assess the success of the project?

Brief description of external or internal funds available (if none, type "none")

A copy of the generated e-mail will be sent to the e-mail address you provided