Grant Application Form

Title *
First Name *
Last Name *
Position in Organisation *
Name of Hospital and department or organisation *
Your Email Address *
Correspondence Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Telephone Daytime *
Telephone Evening
Are you part of, or affiliated to, a larger hospital trust or community organisation?

Please give us as much detail here of the equipment/project(i.e. exact location, how the wider community will benefit, other amenities organisations, businesses in the area- an estimation of the number or people that are using these facilities (number of members, people attending , groups or clubs in the area?) - Please also ensure you provide a description in lay terms, for the non medical members of the grant committee.
Please state which structure your organisation comes under *

How much are you requesting(Including VAT) *
Are you seeking or have you received funds from any other organisation?
Name of Supplier
Address of Supplier
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Suppliers/Providers cost estimates if available
Will the outcome of the project require ongoing maintenance?

It is a condition of the Sussex Heart Charity that it may publicise bursaries that are made. Please confirm that this is acceptable to you. *
Agreed
How do you propose to recognise the support of The Sussex Heart Charity for your project? e.g. plaque, mention in newsletter, programme, press release etc. Please give details below *

Please tick to acknowledge that you have read and understood the terms of the agreement. *
Please Read: Criteria for Successful Grant ApplicationsAgreed
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
If your application is approved you will be responsible for carrying out regular checks and the ongoing maintenance of the device, including the renewal of pads and batteries *
Agreed