*Name of Library

*Librarian

*Mailing address

*City *State *Zip

*County

*Phone number including area code

*Email

*One or more items being requested
(Please use a (.)period between items listed)

*Cost of items $

*Amount of Matching Grant Requested $
  (Not to exceed $1000)

Please forward a quote for the requested items to the system office electronically or by mail.

A paid receipt for the item(s) must be sent to the system office by December 16, 2013 along with any unencumbered funds.

• I certify that my library has, or will have as of the date of this application, the matching cash on hand in order to qualify for the Technology Grant.

*Librarian or Board Chair

*Date

After submitting the application, a web display page should appear and also an email confirmation should come to the email address you input in the application. Print a copy of the email confirmation page for your files.