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DIVISION OF ADMINISTRATIVE SERVICES AUTHORIZATION TO PREPARE A (Mississippi Delta Community College)

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Appendix “A”
1
DIVISION OF ADMINISTRATIVE SERVICES
AUTHORIZATION TO PREPARE A GRANT APPLICATION
(A copy of the grant solicitation documents must accompany this form)
Principal Investigator/Project Director:________________________________________
Tel#: _________________________ E-mail#:_________________________________
IRB Approval Needed: □Yes □ No
Proposal Title: ____________________________________________________________
Submission Deadline: ______________________________________________________
Academic Division: ______________________ Bldg/Rm#: ________________________
CTE Division: __________________________ Bldg/Rm#: ________________________
Type of Application: □ New □ Competing Renewal □ Supplemental
□ Revision □ Agency Long Program □ Non-Competing Continuation
□ Other ____________________________________________________
Funding Agency/Org.: __________________________________________________________
Type of Agency/Org.: □Federal □State □Foundation □Corporation □Other__________
Check One: □ Research □ Demonstration □ Facilities Request □ Instructional Program
□ Fellowship or Traineeship □ Service program □ Equipment Request
□ Other
Amount Requested: _____________ No. Yrs. Funding: ____Funding Period: ______________
Indirect Cost Percentage Rate:__________________
**************************************************************************
If required, have clearances been obtained for the use of the following?:
Facilities (building, rooms, offices, etc.) □Yes □No
Equipment (furnishing, machinery, etc) □Yes □No
Services (health, food, housing, etc.) □Yes □No
Other _________________________________________________________________________
Describe the space needed to house the project (include labs, square footage, proposed location,
etc.)
Appendix “A”
2
______________________________________________________________________________
______________________________________________________________________________
Will matching funds be required for the project? □Yes □No If “yes”, indicate below how this
requirement will be met.
Total matching funds required: ___________________________
Sources of Matching:
A. Institutional Resources (cash) $ _________________
B. In-kind personnel services $ _________________
C. In-kind support services (i.e., computer, time, phone, etc.) $ _________________
D. In-kind supplies, equipment, furnishings $ _________________
E. Other (i.e., office space, etc.) $ _________________
Will student(s) be employed by the project? □Yes □ No If “yes”, indicate how many _________
Will the project require new faculty or staff? □Yes □ No If “yes”, please list positions to fill.
Note: Consultants will be employed for duration of project.
______________________________________________________________________________
Will other College employees be required to devote time to the project? □ Yes □ No
If yes, will the employee be reimbursed for employee time and effort? □ Yes □ No
Project requirements (Check the appropriate box if the proposal requires any of the following):
□ Conference/Public Presentation □ Human Subjects □ Biohazards Review
□ Animal Welfare □ Student Support □ Faculty Release Time
□ None Apply
Brief Explanation for Above_______________________________________________________
___________________________________________________________________________
What commitments will be required beyond the date of project funding? □ None □ Absorption
□ Other _______________________________________________________________________
CERTIFICATE FOR APPROVAL
By signing below the designated Campus Representative(s) have approved this authorization form.
PI/Project Director: ___________________________________________ Date: ____________
Division Dean, Chair, Vice President: ____________________________ Date: ____________
VP/Administrative Services: ___________________________________ Date: ____________
Please return to the office below at least 45 business days before writing actual proposal:
Office of the Vice President of Administrative Service
Tanner Building
Office#: (662) 246-6304
Appendix “A”
3
Do Not Write Below This Line – For Office Use Only
□ Approved Proposal Number: _________________________
□ Disapproved – This proposal was not approved for the following reasons:
President: _____________________________________ Date: ___________________
Mississippi Delta Community College does not discriminate on the basis of race, color, national origin, sex, disability, or age in its
programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies:
The Associate VP for Institutional Effectiveness, Boggs-Scroggins Student Services Center, P.O. Box 668, Moorhead, MS 38761,
662-246-6558.
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Completed 19 September 2020

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