WERF Use Only
Date Received
I.D.#
2015 UNSOLICITED Research Program Pre-Proposal Cover Sheet
PROPOSER INFORMATION
Proposer Name:
Proposer’s Position Title:
Organization:
Mailing Address:
Mailing Address (cont.):
City, State, Zip & Country:
Phone and Fax:
E-mail:
TYPE OF ORGANIZATION
Public
Private Non-profit
For Profit
Federal
State
Local Government
Disadvantaged Business Enterprise (DBE)
 Yes
percentage of WERF cost*
 No
Justification for no DBE, see page
WERF Subscriber?  Yes
 No
PROJECT INFORMATION
RFP or Pre-proposal Identifier: 2015Unsolicited Research Program
Title:
Proposed Project Period:
WERF Cost
In-Kind/Other Support
$
RESEARCH OR DEMONSTRATION
 Is this research?
 Or a technology demonstration?
TOTAL Project Cost
$
$
If Research, DOES THIS INVOLVE?
Human Subjects?
 Yes
Vertebrate Animals?
 Yes
Recombinant DNA?
 Yes
 No
 No
 No
AUTHORIZED SIGNATURES
Principal Investigator
I agree to accept responsibility for scientific conduct of the project and to provide the required project
reports if a contract is awarded as a result of this application.
Signature:
Date:
Name:
Designated Official Responsible for Contracts in the Proposer’s Organization
To the best of my knowledge, this organization can comply with the WERF policies and contractual
conditions listed in Section VI of the instructions.
Signature:
*WERF’s DBE goal is a minimum of 15% of WERF cost
Date:
Name:
vi