1.Your Name Mailing Address City State Zip Email Work Number: Home:
2. Name of Your Project 3. Sponsoring Organization 4. Year that you received a BLF Grant
5. Was your project continued after your fellowship? Yes No Please Explain:
6. Does your project still exist today? (Please include any subsequent modifications such as name changes or incorporation into the supporting organization)
7. What were the major successes of your project?
8. What impact did your project have on the intended community?
9. What is your most memorable moment from your project?
10. How did the BLF fellowship affect your career?
11. What other jobs/positions have you had since receiving the Fellowship?
12. Is there any other new and exciting information that you would like to share:
13. Can we quote you and/or use the pictures and other memorabilia that you send us? Yes No
14. Would you like to speak at our 25th Anniversary event this spring? Yes No
Thank you for taking the time to fill out this questionnaire!
Please remember to send in any pictures and/or other memorabilia!