Grant Request Form - page 1

American Wildlife Conservation foundation, INC.
William C. Churchill fund – Karl T. Fredrick memorial Fund
CONSERVATION – EDUCATION – RESEARCH

John Hasenjager, Grants Comm. Chair
American Wildlife Conservation Foundation
5698 State Route 23
Cincinnatus, NY 13040
Email: jhas@frontier.com

Title of Proposal: ______________________________________________________________ ____________________________________________________________________________

Type of Project: _______________________________________________________________

Name, Affiliation and Address of principal Investigator or Leader: ____________________________________________________________________________ ____________________________________________________________________________

Amount Requested: $ _________ Telephone – Work: (    ) __________ Home (    ) __________

Duration of Project: ____________________________________________________________

Agency and Address of Agency to Receive Grant:
_________________________________________
_________________________________________
_________________________________________
_________________________________________

Signature of Applicant: ___________________________________

Title:  _______________________________
Date: _______________________________

Signature of Supervisor or Agency Representative: ______________________

Title: ________________________________
Date: ________________________________

Mail original and 5 copies to Grants Committee (above) by February 1 (summer work) or by
August 1 (for next calendar year).

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