A. Contact Information

---

• Name of the Applicant Organization
• Name and Title of the Principal Contact Person
• Street address
• City, State, and Zip Code
• Country
• Phone Number
• Fax Number
• E-mail Address
• Website URL

---

B. Project Information

---

Indicate which Award Category applies to your submission:

• W. Raymond Mize, Jr., MD Technology in Health Care Award
• Projects to improve Health Care in Latin America/Caribbean
• Clinical Engineering
• Technology Nano Grant
• HIV Health Care
• Or a other area of concern

Briefly describe:

The project goals, organization, and timing of the project. Include the educational levels/areas of expertise of the performers. Statements of how:

• The project will stimulate others and meet the goals of the ITHC.
• How, where, and when the applicant organization will announce and present the ITHC Award.
• The minimal amount of funding to accomplish the project.
• Detailed budge of how the funds will be spent.
• If the applicant is a USA organization, provide IRS Non-Profit Status. If not a USA organization provide credentials/accreditation as to Non-Profit Status. Provide Tax-Exempt status.
• Is your project unique? Are there other organizations sponsoring the same or identical or closely related work?

---

C. Permission and Acknowledgement Statements

---

Permission must be given to The Institute for Technology in Health Care to reprint, publish, or detail on our website. The preferred acknowledgement statement is:
"This award is supported by a grant from The Institute for Technology in HealthCare, a non-profit organization, located in Washington, DC. The Institute for Technology in HealthCare is concerned with the use of technology to benefit and stimulate others in health care. For more information about The Institute for Technology in HealthCare please visit the website at www.ithcawards.org."

---

D. Submissions

---

Please email your submission to:
Jacqueline W. Schick, Board Secretary jschick@ithcawards.org

---