Apply For A GrantApply by Nov.1

Organization EIN Number:

Year:

Organization Name:

Organization Mission:

In one sentence, describe the project for which you are applying for funds:

Mailing Address:

Street Address:

City:

Postal Code:

Site Visit Address:

Street Address:

City:

Postal Code:

Agency Director & Title:

Electronic Signature of Agency Director:

Contact Person & Title:

Phone:

Fax:

Email Address:

Amount requested:

Purpose:

Operating Support

Capital Expenditure

Program/Project

Other

Area of Support:

Housing

Education

Other

Number of Adults to be served:

What percentage of this population are women:

For what specific purpose are these funds being requested?:

Who will be served by the project?:

What is the need for your request, in both your financial situation and for the community?:

If the project/program is on going, how will it be funded in the future?:

Please list additional sources of support being approached for this specific project/program:

List grant applications to this foundation during the past five years:

Please provide your agency's number of full-time employees:

Number of part-time employees:

Number of volunteers: