Mid-Atlantic Robotics Grant Application
Team Information:
Team Number: ______ Team Name:____________________ E-mail contact: _________________________
Adult Contact: _____________________ Phone: _____________ Signature:_____________________________
Team Member Name and Position: ________________________Signature:_____________________________
If approved, make check payable to:______________________________________________
Mailing address: Name: _______________________________________
Organization: ___________________________________________________
Street/P.O. Box Address: ____________________________________________
Post Office, State/ZIP:____________________________________________
Season Specific Information
If your team is attending a regional event outside of MAR, which one(s)? ________________________________
If already registered for the World Championship, are you confirmed _____ or on waitlist ____? (check one)
If your team is planning to carry over any funds from this year for next season, how much? $____________
Grant Specific Information:
Type of Grant (check one): Championship Event -___; Rookie Support -___; Emergency Issue – ___
Amount being requested: $__________ Specific Use(s) of Grant: _________________________________
___________________________________________________________________________________________
Why needed (250 words max with reference to budget and extenuating circumstances, e.g. loss of sponsor or prior funding commitment, etc):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Attach team budget. Teams which do not provide a budget will be ineligible for a grant. See Rules for Grants.
Submit application to: Gene R. O’Brien at HYPERLINK “mailto:grob.group@rcn.com” grob.group@rcn.com (Lead Member of 2012-13 Grant Review Team)
(Documents may be in word.doc, word.docx, pdf, or Excel formats)
—————————————————-**********************————————————————————-For Review Team Use Completed Grant Application received on _________________
Amount approved by the Review Team: $____________ Approval Date: _______________Grant Check Request Number: GCR-_____
Check 1: [ ] Pass-through Grant [ ] Short term Loan [ ] Grant from General Fund
Grant Application Form Issue 2 (Dec., 2012)