Date of Application
Legal Name of Organization
(Should be the same as on IRS determination letter and as supplied on IRS Form 990)
Year Founded
Current Annual Operating Budget: $
Executive Director
Email Address
Contact Person/Title (if different from Executive Director)
Address (principal/administrative office):
City
State/Province
Postal/Zipcode
Mailing Address, if different from above:
Phone number
Fax
Website
Project Name
Purpose
Amount Requested: $
Total Project Cost: $
Project Goals
Beginning Date of the Project/Campaign
Ending Date of the Project/Campaign
Geographic Area to be Served
Signature of Executive Director
Date