• I. Agency Contact

  • Address
  • II. Funding Request

    Funding will be on a matching basis. The Medic One Foundation may contribute up to 75% of the cost of the requested equipment.

    (Please list only the total amount of requested funds by category on this page. If you are requesting a grant for more than one item, please include an itemized list of your funding request in section IV. Requests for equipment costing $1,000 or more must include two vendor bids verifying the cost.)

  • Medical Equipment:

  • Amount Requested
  • Matching Funds from Agency
  • Total Cost
  • Other:

  • Amount Requested
  • Matching Funds from Agency
  • Total Cost
  • Total:

  • Amount Requested
  • Matching Funds from Agency
  • Total Cost

  • III. Agency Information

  • AGENCY RESPONSE INFORMATION

  • DEMOGRAPHIC INFORMATION

  • PERSONNEL

  • IV. Budget

  • Do you have a depreciation funding plan for the requested equipment?:
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  • Accepted file types: doc, pdf, txt, gif, jpg, jpeg, png.
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