* 1. Contact Name

* 2. Contact Email

* 3. Contact Phone

* 4. Organization Name

* 5. Name of project / initiative

* 6. Major partners/ funding sources

* 7.  What issues does your project/initiative address? (Check all that apply)

* 8. What does your initiative/project do? Briefly describe your project including major goals and activities.

* 9. What geographic areas does it serve? (Check all that apply)

* 10. What is the target population? Briefly describe the demographics.

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