APPLICANT INFORMATION FORM

Medical Marijuana Research Grant Program October 2014

(Complete one per application)


Agency Name:

Agency Legal Name:


Agency Contact:

Agency Address:

City, State, Zip:

Agency Telephone: Fax: Email:


Administrative Contact:

Administrative Telephone: Fax: Email:


Financial/Contract Contact:

Financial/Contract Telephone: Fax: Email:


Authorized Signature Contact:

Authorized Telephone: Fax: Email:





Project Title:




Requested and Estimated Funding:

Please enter the dollar amount being requested for Project Year 1: $

Please enter the estimated dollar amount for Project Year 2 (if applicable) $

Please enter the estimated dollar amount for Project Year 3 (if applicable) $

TOTAL $