Attachment A_summary

Attachment A
USE THE FOLLOWING FORMAT
EARTH MRI MINE WASTE PROPOSAL SUMMARY SHEET
Proposal Title:
Name of State Geological Survey:
Principal Investigator (person we can call to ask questions if needed):
Name:
Address:
Phone:
Email:
Authorized Institution representative:
Name:
Address:
Phone:
Email:
Project Deliverables:
Priority 1 Amount Requested:
Deliverables:
Priority 2 Amount Requested:
Deliverables:
Priority 3, Travel to Earth MRI Workshop
Please check box: My State geological survey plans to attend workshop
In Person☐ Virtually ☐ Both☐ Do not plan to attend☐
Amount Requested:
Travelers:

Start date:
Total Federal Funds Requested:
Total Matching Funds (Optional):

End date:
$_____________________
$_____________________