NIMH Outreach Partnership Program 2008 Solicitation Organization and Contacts Form
Organizations submitting proposals in response to the Solicitation for the National Institute of Mental Health Outreach Partnership Program must complete this Organization and Contacts Form. Please include the completed form as an attachment in your proposal.
Organization Information
| Organization Name | |
| Street Address | |
| City | |
| State | |
| Zip Code | |
| Phone | |
| Fax | |
| Web Site URL | |
| Email Address | |
| Tax Identification Number |
Primary Contact Person
Enter contact information about the person that will be responsible for the management of the organization’s work for the Program and serve as the primary point of contact for NIMH staff. Please also include a resume for this person as an attachment to the proposal.
| Prefix | |
| First Name | |
| Last Name | |
| Degree | |
| Title | |
| Street Address | |
| City | |
| State | |
| Zip Code | |
| Phone | |
| Fax | |
| Email Address |
Backup Contact Person
Enter contact information about the person that will serve as the backup contact for your organization’s work for the Program. Please also include a resume for this person as an attachment to the proposal.
| Prefix | |
| First Name | |
| Last Name | |
| Degree | |
| Title | |
| Street Address | |
| City | |
| State | |
| Zip Code | |
| Phone | |
| Fax | |
| Email Address |
Executive Director
Enter contact information about the organization’s Executive Director or equivalent.
| Prefix | |
| First Name | |
| Last Name | |
| Degree | |
| Title | |
| Street Address | |
| City | |
| State | |
| Zip Code | |
| Phone | |
| Fax | |
| Email Address |
Scientific Advisor
Enter contact information about the person who will serve as your organization’s Scientific Advisor for the Program. Please also include an abridged CV for this person along with a signed letter of commitment as an attachment to the proposal.
| Prefix | |
| First Name | |
| Last Name | |
| Degree | |
| Title | |
| Organization | |
| Street Address | |
| City | |
| State | |
| Zip Code | |
| Phone | |
| Fax | |
| Email Address |
To receive this document in PDF, please email partnerssfpnimh@mail.nih.gov.
