PILLING GRANT REQUEST FORM – Derbyshire Archaeological Society

Monica Pilling Award

Full Name

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Post Code

If correspondence address is different please provide details .

Correspondence Address Details

Telephone number: Landline

Telephone number: Mobile

Email address

Qualifications

Project title

Brief description of project

A fuller report, maps and/or plans may be submitted in support, if appropriate

Project aims

Details of any permissions needed

e.g. English Heritage

Proposed start date

Expected duration of project

Expenditure for which award is sought (Awards will not normally exceed £1000)

Total Sum

Approximate breakdown of cost

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Please state what other funding will be applied for, if any

Additional Information