EmailMe Form - Grant Coaching/Review Service Reviewer Application

Name *

First Last

Organization

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

Phone *

### - ### - ####

Education *

Professional Background

List of skills and/or competencies relevant to the Grant Coaching and Review Service

Summary of service experience on federal-level Independent Review Boards

References: Please list 3 references who are familiar with your relevant experience. These will will be contacted by phone or email.

	Name	Phone Number	Email Address
Reference 1
Reference 2
Reference 3

Terms of Agreement

If selected as a Grant Coach of the NCHN Grant Coaching and Review Service Program, I agree to the following:
• In order to avoid conflicts of interest, I will only contract with one organization (whether a member or non-member) for each grant review opportunity.
• Only reviews contracted with NCHN members through NCHN’s service will be offered at the NCHN discounted rate.
• NCHN’s Grant Coaching and Review Service will be offered at the rate of $145/hour. Of the hourly fee of $145, the reviewer (you) will retain $105/hour and pay $40/hour to NCHN as a Client Finder Fee.

Agreement *

I have read and agree to the terms above