Organization Name
Contact Name
Contact Title
Organization Address
Mailing Addres (if different)
Phone
Fax
E-mail
Please describe the mission of your organization
Which area of community development does your request best serve?	Education Elderly Health and Welfare Child Health and Welfare Public Safety Social Services Infrastructure Improvements Environmental Stewardship Indian Country Humboldt County
Total contribution amount requested
What segment of the population is principally served by your organization�
Has your organization received prior funding from Blue Lake Rancheria	yes no
If so: Date and Amount
What is the purpose of this request, how will the requested funds be used and why the Blue Lake Rancheria should support this request
If this request is part of a fund-raising campaign:
What is the total dollar goal of the campaign
What is the total of pledges/contributions committed to date
Please provide the names of organizations from which pledges or contributions have been received and include dollar amounts committed.
What is the annual income of your organization
Please identify the main source(s) of income	Ticket Sales or other fees Membership and individual contributions United Way or other public charities
-or-
Corporate donations (specify)
Government funding (specify)
Other Foundations (specify)
Other
General Comments