1. Application Date:
________________________________

2. Project Title:
________________________________________________________

3. Applicant:
________________________________________________________

4. Address, Phone, Fax:
________________________________________________________

5. Co-operating Partners:
________________________________________________________

6. Project Background
________________________________________________________

7. Proposed Project Objectives:
________________________________________________________

8. Project:
________________________________________________________

9. Budget:

Salaries
________________________________________________________

Materials
________________________________________________________

Equipment (specify)
________________________________________________________

Lab Costs
________________________________________________________

Other (specify)
________________________________________________________

TOTAL Project Funding
________________________________________________________

Less Funding from other sources
________________________________________________________

Funding Amount Required from WCTA
________________________________________________________

10. Project Starting Date:
________________________________________________________