EmailMe Form - SUMMARY OF APPLICANT ORGANIZATION

Organization Name: *

Fill out your address below *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Executive Director *

Prefix First Last

Contact (if other than Executive Director)

Prefix First Last

Job Title

Your Email *

Phone Number *

### - ### - ####

Your Website

Purpose of Grant

General operating (support for organization as a whole)

Special program/project (support for specific activity of the organization that is consistent with its mission)

Start-up costs

Endowment

Technical assistance

Other

Brief description of request *

Organization budget: *

Program budget (Only if applying for special program)

Fiscal year *

Fiscal year ends *

Amount of Request *

Signature, President, Board of Directors

Clear

Use your mouse, screen or touchpad to sign.

Date *

MM / DD / YYYY

Signature, Executive Director

Clear

Use your mouse, screen or touchpad to sign.

Date *

MM / DD / YYYY

PROJECT NAME *

PROGRAM/PROJECT BUDGET—

FOR SPECIAL PROGRAM REQUESTS ONLY

Itemize Expense

Cost

Itemize Expense

Cost

Itemize Expense

Cost

Itemize Expense

Cost

Itemize Expense

Cost

Itemize Expense

Cost

Itemize Expense

Cost

Itemize Expense

Cost

TOTAL COST (A)

FUNDS AVAILABLE FOR PROGRAM—

FOR PROGRAM REQUESTS ONLY

Gifts & Grants (pledged or paid)

Trustees

Corporations

Foundations

Individuals

Government

Other (earned income, special events, membership, subscriptions, etc.)

TOTAL FUNDS AVAILABLE (B)

BALANCE REQUIRED (A minus B)

AMOUNT REQUESTED

CLICK HERE for File Upload

For multiple files, .zip them together and upload.

PROGRAM/PROJECT BUDGET— FOR SPECIAL PROGRAM REQUESTS ONLY

FUNDS AVAILABLE FOR PROGRAM— FOR PROGRAM REQUESTS ONLY

PROGRAM/PROJECT BUDGET—

FOR SPECIAL PROGRAM REQUESTS ONLY

FUNDS AVAILABLE FOR PROGRAM—

FOR PROGRAM REQUESTS ONLY