Letter of Inquiry Submission Form

Thank you for your interest in working with the Blue Cross & Blue Shield of Mississippi Foundation. The first step in applying for a Blue Cross & Blue Shield of Mississippi Foundation grant is to submit a brief Letter of Inquiry. Please use the form below to make your submission. Once your Letter of Inquiry has been reviewed, you will receive one of the following:

A request for more information
A request for a full grant application
A letter informing you that the Foundation has elected not to fund your project

Your Contact Information:	Please complete all items.

*1) First name:	*7) Your mailing address:

*2) Last name:	8) Your apt or suite (if required for delivery):

*3) Your email:	*9) Your city:

*4) Your phone:	*10) Your state:
	I am a legal resident of the State of Mississippi.
*5) Organization/Group Name:	*11) Your zip code:

*6) Project Name:


*12) Briefly describe the issue the project seeks to address:

*13) Into which of the Foundation's areas of interest does your project fit? Children's Health and Wellness Community Health Initiatives Promotion of Healthy Lifestyles and Choices
*14) How do you define success for the program, and how will you measure it?

*15) Provide information about key personnel who will lead the project, and about their qualifications:

*16) Provide an estimate of the project's total budget:

*17) Indicate the amount of financial support you seek from the Blue Cross & Blue Shield of Mississippi Foundation:

*18) Explain how funding from the Foundation will help achieve the goals of the project:

*19) Explain how the project could be easily replicated to serve as a model for other communities in the state:
*20) Please re-enter your zip code to confirm.
* Required Fields