Grant Application Form Please fill out the following information to be considered for the Hamilton Grant. Grant Application Section 1: Personal Information First Name * Last Name * Institution/Company * Title * Department Name * Phone Number * Email Address * Mailing Address * Bldg, Room No. or Mail Stop City * State/Province * Zip/Postal Code * Section 2: Grant Application Questions Number of undergraduate students in your department: * Number of graduate students in your department: * Section 3: Course(s) in which Hamilton products will be used: Course Number Title Instructor Name Brief Overview Add Remove Section 4: Additional Details Which Hamilton syringes is your lab interested in? * Describe the application or technique where the syringes or needles will be utilized. * How will the syringes and needles you receive from this product grant benefit your students, your lab, and help you achieve your educational goals? * For your application are there any changes or modifications to the current syringes or needles that would improve your application or technique if addressed? * Feel free to share anything else about you, your classmates or your lab that sets you apart or will help us make a decision. * Are you 18 years of age or older? * Yes No By checking this box and submitting this form, I understand and agree to the Grant Program Terms and Conditions. * Accept By checking this box and submitting this form, I state that Hamilton Company has the right to publish or advertise the results of the scientific application I have described above. Anyone on the research team will be acknowledged in materials but will not be compensated. * Accept Questions regarding the grant program may be directed to Don Carine at firstname.lastname@example.org or 775-858-3000 ext. 457.