Wireless Reach Proposals: 2012

Project Title

Project Location

Country

Contact Information of Contact Filling Out Form

Organization Name

First Name of Contact Filling Out Form

Last Name of Contact Filling Out Form

Job Title of Contact Filling Out Form

Email Address of Contact Filling Out Form

Work Phone Numberof Contact Filling Out Form

Mobile Phone Number of Contact Filling Out Form

Street Address of Organization

City of Organization

State / Province of Organization

Zip Code of Organization

Country of Organization

Project Information

Type: Education, Entrepreneurship, Environment, Health Care, or Public Safety

Wireless Reach 2012 Budget Request

Requested Funding (Amount in USD)

Qualcomm Technology

Technology Description

Funding Supports

A)State precisely what Wireless Reach dollars will fund.

B)Who is the recipient of those dollars?

C)What will be the measurable outcomes/milestones by quarter?

D)What will be the measurable outcomes/milestones one year after the start of implementation?

Project Description

A)Please include the goal, target beneficiaries, and the need that will be addressed through this project.

B)Describe how Qualcomm technology will be used in the project.

C)How will this project be sustainable? (For example, after the project has been funded, will the recipients of the grant be able to maintain and grow the services? Does the project have any built in revenue mechanism?)

Partners – Their Roles and Contributions

Describe the roles of partners and their incentive for making the project a success in the fields below and include a US Dollar amount for their contribution whether in-kind or cash. Also state whether the partner is confirmed or tentative.

Partner Name / Partner Description / Service Provided / Cash or In-kind Contribution / Valued Amount in USD$ / Confirmed or Tentative

Supporting Information

  1. Background information on your organization.
  2. How doesthe proposed project meetthe goals of your organization and promote country goals (ICT, education, health care, etc.)? Please state any relevant public government initiatives.
  3. How doesthe proposed projectdemonstrate that advanced wireless technologies can improve people’s lives in the areas of education, health care, entrepreneurship, public safety or the environment?

Project Sustainability

A)What is the plan to monitor and evaluate the progress of the project against the stated goals and objectives?

B)What organization will conduct the above stated monitoring and evaluation plans (your organization or another organization)?

Project Leads

First Name

Last Name

Organization

Title