Working with individuals, local, national, and global communities in creating preventive culturally sustainable health and education solutions!

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STRATEGIC PROGRAM SERVICE PROPOSAL FORM

Confidential Request for a Grant Development Dialogue

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Invest a few minutes with us, and you will discover how experienced our staffs are, and how delightful and affordable our services are. And what's more, our initial services:
ALL FOR FREE!

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Please complete this form to begin a free one-hour dialogue for our Strategic Program Services:

1. Tell us about your and/or your organization:

Name of Organization:
Address:
E-Mail Address:
Phone Number:
Best time to contact:
Fax Number:
Web Address:
Contact Person:
Title:

2. Please identify the primary services provided by your type of organization:

TYPE OF ORGANIZATION	INFORMATION	EDUCATION	SERVICES
Faith-based organization
Government agency
Public non-profit organization
Private non-profit organization
Community-based organization
college/university
For profit health
Others

3. Focus of Program [Please circle only one]:
    Provide information           Provide education             Provide services     Change attitude            Change behavior
    Problem solving                Create infrastructure         Coordinate efforts    Determine unmet needs
    Others Please specify

4. Who will be primary beneficiaries of project/program [Please circle only one]:
    Low Income Community   Minority Communities        Pregnant women     Fathers                        Homeless Population      Teens
    Others Please specify

5. What is the expected overall outcome for this project/program?

6. Your Deadline (if one has been set):                                                                                                                          

7. Estimated Budget Range:                                                                                              

8. Is there any other information you'd like to tell us that will help us with your project?

9. How did you find out about HINS?

A printed copy of this form and/or other relevant documents may also be sent by mail or fax to:

Health International Network System 3168 Thirty Fifth Street South, La Crosse, Wisconsin 54601, USA Phone: +608.787.8997   +608.317.9131   +Fax: 608.787.6660

HINS/AOJ/05/001/2