Budget: Item Amount Total cash funding requested in this application. $ Please indicate an estimate of how funds will be spent: Total hours of HIC staff time requested as in-kind support. $ Please estimate below the type and quantity of input at $150/hour: Contribution (cash and/or in-kind) from your health service for $ the project Total budget (cash and in-kind from HIC) for the project $ Are there other sources of funding being sought or secured from your organisation or externally for this project? Yes No If yes, please complete below: Organisation Amount Cash or In-kind? Secured? Cash In-kind Yes No Cash In-kind Yes No Cash In-kind Yes No
Budget: Item Amount Total cash funding requested in this application. Please indicate an estimate of how funds will be spent: $ Total hours of HIC staff time requested as in-kind support. Please estimate below the type and quantity of input at $150/hour: $ Contribution (cash and/or in-kind) from your health service for the project $ Total budget (cash and in-kind from HIC) for the project $ Are there other sources of funding being sought or secured from your organisation or externally for this project? Yes No If yes, please complete below: Organisation Amount Cash or In-kind? Secured? Cash In-kind Yes No Cash In-kind Yes No Cash In-kind Yes No
HIC-application-form-practice-partners-program1.docx