2019 Global Outreach Grant & Robert K. Pedersen Global Outreach Grant
Application Form

Step 1: Review requirements document.

Step 2: Fill out form below and upload all required supporting materials.

Application Deadline: July 12, 2019

Applicant Information

Name of Applicant *

AAPA ID # *

Applicant Status *

Practicing PA

PA Program Faculty

PA Student

Applicant Street Address *

Address Line 2

City *

State *

Zip Code *

E-mail Address *

Phone Number *

Fax Number

If applicant is a student, name of faculty sponsor

PA Program

Applicant Organization Information

Applicant Organization Status *

PA Program

Constituent Organization

Nonprofit Organization

Applicant Organization Name *

Name and Title of Contact at Applicant Organization (if different than applicant) *

Applicant Organization Address *

Address Line 2

City *

State *

Zip Code *

Phone Number

Fax

Is this organization incorporated? *

Yes

No

Is this organization a non-profit? *

Yes

No

Project Information

Project Title *

Brief Description of Project (250 word maximum) *

0/250 words

Funding Requested *

Total Project Budget *

If selected as a grantee, check should be made payable to (organization name): *

Attestations

Please review and indicate your agreement with the following statements by checking the box next to each. *

I attest that the contents of this grant application are true and accurate. I agree that if awarded a grant, information about this project and my photograph may be published in AAPA and PA Foundation publications and news releases.

I attest that the individuals and organizations applying for this grant do not advocate, support, or engage in discrimination in the provision of health care on the basis of age, color, disability, ethnicity, gender identity or expression, national origin, union membership, political affiliation, race, size, religious affiliation, sex, sexual orientation, or socioeconomic or veteran status.

Signature of Applicant *

clear

Date: +

Applicant Organization Attestations
To be signed by main contact at applicant/sponsoring organization; if the individual applicant is affiliated with the applicant organization, form should be signed by the applicant's supervisor (or the applicant him/herself, if no supervisor).

View and print Applicant Organization Attestation Form.

Upload signed Applicant Organization Attestation Form.

Faculty Sponsor Attestations (if applicant is a PA student)

View and print Faculty Sponsor Attestation Form.

Upload signed Faculty Sponsor Attestation Form.

Required Documents

Attach detailed project budget. *

If project is to be conducted outside of the U.S., attach document of support from host country (see item #3 under "Application Requirements" in the requirements document).

If project is to be conducted within the U.S., attach letter of support from the humanitarian organization with which you will be working (see item #4 under "Application Requirements" in the requirements document).

Attach written proposal (maximum 8 pages) addressing the items/questions included in the requirements document (see item #5 under "Application Requirements" in the requirements document). * 🛈