OPIOID FUNDING PROGRAM
Please provide all required details to apply for Opioid program funding
Personal Information
Full Name:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Personal Phone Number
Format: (000) 000-0000.
E-mail:
*
example@example.com
Organization Information
Organization Name:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Organization Phone Number
Format: (000) 000-0000.
Org Website:
https://www.myorganization.com
If a 5013c, Is your Non-Profit Status in good standing in New Jersey?
Yes
No
Unknown
Fund Request
Purpose: (choose one)
Prevention
Recovery Support
Treatment of Substance Use Disorder
Harm Reduction
Education & Awareness
Evidence-Based Data Collection & Research
Serving Specialty Populations
Support of Families
Requested funds for:
New Program
Existing Program
Qualification of Funds:
Evidence Based Request
Evidence Informed Report
Neither Apply
Targeted Impact:
Evesham Township Residents
Burlington County Residents
State of New Jersey Residents
Out of State Residents
Targeted Population:
Youth/Under 18
Adult/Above 18
Family
Other
Has opioid funding been used to fund the requested program prior?
Yes
No
Request Overview
Project Title:
Detailed Explanation of Program the Requested Funding will be Used For:
Define Benchmarks That Will Be Used to Determine Program's Success:
Detail Budget for the Requested Funding:
Opioid Funds Will Fund What Percentage of This Program's Cost:
If Funding for This Program Is Not Fully Funded by This Request, Detail the Source of the Additional Funding:
Have you Applied for Other or Prior Opioid Funding?
Yes
No
If Yes, Detail Prior Requests/Funding Programs:
Data Collection Capacity:
Yes
No
Unknown
Define Data Collection Capacity:
Attach any Supporting Documments:
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