OMB No: 0925-0740
Expiration Date: 05/2019
Sign-up Form for Non-profit Organizations interested in
Providing Resources for Matching Funds for the NIH HEAL Initiative
I am requesting to list my organization’s contact information on a government website noting my interest in partnering with for-profit small businesses applying for NIH research funds through the NIH Helping to End Addiction Long-term (HEAL) initiative.
Organization Name: ______________________________________________
Organization’s Website/URL: ___________________________________________
Contact Person’s Name: ___________________________________________
Contact Person’s Telephone: ___________________________________________
Contact Person’s Email: _______________________________________________
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0740). Do not return the completed form to this address.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Donna |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |