Grant Assistance Application Form

General Devices is pleased to be able to assist you in your grant funding efforts.

To initiate the General Devices Grant Assistance Program, simply complete the following form and you will be contacted by our Grant Assistance advisor within several days. Any personal information submitted is used for its intended purpose only. No information collected by General Devices is disclosed to any third party for any purpose unless required by law.

Note that the entries with an asterisk (*) are required, as is the anti-spam “math” screener at the bottom of the form.

If your need is more urgent, please call us at 201-313-7075.

Entry Date: *

Hospital/Agency Name: *

Hospital/Agency Type: *

Street Address: *

City: *

State: *

ZIP Code: *

Name: *

Title/Position: *

Email: *

Phone Number: *

Best Time to Call: *

Use Eastern Time Zone

Additional or Alternate Contact Name:

Additional or Alternate Contact Email:

Additional or Alternate Contact Phone Number:

Tax Status: *

Type of Assistance Needed (check all that apply): *

Finding a grant

Writing the grant proposal/application

Managing a grant

Other (describe in “Describe Your Needs” below)

Describe your needs:

As applicable, describe your communications infastructure:

If you are an EMS Agency, what hospitals does your service work with?:

If you are a Hospital, what EMS Agencies does your hospital work with?:

What is your timescale for your project:

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Math Question: * 15 + 0 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

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