IEEE WIE Affinity Group Special Funding Request Form This form is to be used for Special Funding requests for IEEE WIE Affinity Groups. Order Number First Name: * Last Name: * IEEE Membership Number: * Email address: * Phone Number: * IEEE WIE Volunteer position: * IEEE WIE Affinity Group Name and Number / Society name: * Title of Activity: * Date of Activity: * Description of Activity: * Provide details of the activity (500 words or less). Include information such as objectives, audience, alignment with IEEE WIE mission/vision, benefits to WIE membership/community, advertising plan, and evaluation of activity.lan, and evaluation of program Total Number of Participants Expected: * Number of IEEE Members: * Number of Non-members: * Identify Other sources of funding solicited. Include sources and amounts requested. * Total Amount of Activity: * Please complete the required Budget Plan document (linked at the bottom of this form) and send to email@example.com. Describe how the effectiveness of the activity will be evaluated. * Important: Funds must be sent by check, wire transfer, or through a concentration banking account. Funds will not be sent to or made out to an individual. If a group does not have an account to transfer funds, the funds may be sent to a Section for forwarding to the group. Provide Section Treasurer (Name/Contact Information): Wire Transfer Information (WIE Affinity Group Transfer): Bank Name: * Bank Address: * City: * Country: * Bank Acct Name: * Bank Acct or IBAN#: * Instructions for Wire: * Internal GL Account Number (Society Transfer): * Concentration Banking Account Number: * Budget Plan*: Please complete the required template and send to firstname.lastname@example.org Your Activity Report must be submitted to email@example.com within thirty (30) days after the conclusion of the activity with details of the use of funds.