Expression of Interest form

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* 1. Nominee

Name of the organization or individual:

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* 2. Name of the specific nominated initiative:

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* 3. Mailing Address:

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* 4. Phone:

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* 5. Fax:

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* 6. Email:

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* 7. Website:

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* 8. Name and title of primary contact:

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* 9. Type of initiative: See Appendix A for a brief description of each category and relevant criteria.

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* 10. Duration of the Initiative

Starting date
End date (If applicable)

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* 11. Provide a basic description of this initiative: How is it linked to agricultural mental health? What is its core purpose, target population, and what primary activities are undertaken to achieve these? (200 words)

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