Grant Application Form

Transcription

1 Grant Application Form Date of Application: Legal Name of Organization: Executive Director: Contact Person/Title: Organization Website: EIN: Address: City, State, Zip: Phone Number: Fax Number: Life Technologies Employee/Site Endorsement: Project Name: Objective of Grant: Period of Performance (# months): Amount Requested: $ Total Project Cost: $ Is your organization an IRS 501(c)(3) not-for-profit? Yes No If no, please explain your organization s status: Please submit this form with the following proposal requirements to Marilyn Parks at: foundation@lifetech.com or 7305 Executive Way, Frederick, MD 21704, USA Thank you to San Diego Grantmakers for allowing the Life Technologies Foundation to use a portion of their Common Grant Application.

2 Instructions for Submission of Proposal The Life Technologies Foundation was created to support science education and advance society s understanding of the importance of scientific endeavors. Grant applicants must first submit a statement of interest on the Life Technologies Foundation Quad Chart. The Life Technologies Foundation will review Quad Charts for their relevance to the Foundation s mission. If your Quad Chart is selected as a potential grant candidate, you will receive written notification requesting a full proposal. Grant requests that are not supported by a Quad Chart and/or applicants who do not receive written notice to submit a full proposal will not be considered. Scope of Work 2009 Areas of Interest This year, the Foundation will support educational initiatives or innovative scientific programs focused on one of three specific areas: Topic 1: Use of genomics to advance the field of personalized medicine For example: Development of curricula for teaching individuals, medical students, journalists, policy makers, and/or physicians the concept of personalized medicine and how to use genetic data to tailor an individual s medical care. Topic 2: Scientific developments in regenerative medicine For example: Work to advance regenerative science, projects for the advancement of cell technology, initiatives to develop stem cell research and knowledge. Topic 3: Application of biology to areas outside of basic research For example: Human identity testing, 21st century forensics, food or water safety initiatives, advancement of molecular diagnostic tools, education of legislators, development of educational materials, creation of a genetics and policy center. Terms and Conditions of Grant An applicant may request up to $500,000 (US dollars). Work must be performed and completed within 12 months from date of grant award. Grant award is contingent upon mutual acceptance of a Grant Agreement. Evaluation Criteria Quad Charts and proposals will be reviewed and considered at the sole discretion of the Life Technologies Foundation. Priority will be given to those applicants who focus on the 2009 areas of interest listed above.

3 If your Quad Chart is selected for further consideration, you will receive written notification to submit a full proposal. When submitting a proposal to the Life Technologies Foundation, provide the following information in the order indicated, including the headings and subheadings specified below. Prepare proposals using Times Roman, 12 point font, with.5 margins. I. Objective (one page or less) A. State the purpose of the proposed grant. Describe the proposed program, its goals, and its objectives. Identify the needs, challenges, and/or opportunities.

4 II. Organization Information (200 words or less) A. State the organization s mission and goals; summarize the organization s history. III. Benefits of Proposed Concept (500 words or less) A. Explain how this program relates to the mission of the Life Technologies Foundation. B. Describe program challenges and how your organization will plan to resolve those challenges. C. Describe why your organization is best qualified to manage this program.

5 IV. Metrics (One page or less) A. Describe the program s results, milestones, and/or goals. (for example: Reports, meetings, press releases, seminars, training programs, etc.) B. Describe how you will evaluate the success of this program. (for example: Metrics at program completion and/or benefits for the biotechnology community) C. Provide total projected costs for labor, material, and overhead. Provide Attachment A to show budget detail. (See below.) D. Describe the period of performance, and/or suggested or required start/end date. E. If your organization will receive additional funds to support this program, identify the contributors and amount of their donations.

6 Attachments to Proposal A. Project Budget Detail (one page) B. Current IRS determination letter for 501(c)(3) tax-exempt status C. Board of Directors and their affiliations D. A list of other supporters/potential supporters and amounts committed/requested for the project E. Organizational financial statements From the last two (2) fiscal years (audited if possible) Current operating budget (expenses and income) F. Annual Report (if available)