Form

BASIC INFORMATION
Name:
Title:
Company/Organization
Address:
City:
State:
Zip code:
Phone:
Fax:
E-mail:
Website:
ORGANIZATIONAL DESCRIPTION
Mission/Purpose:
Geographic Area Served:
Number of Employees:
Annual Budget Size:
Funding Sources:

State Federal Town Foundation Corporation Individual Donors Other
Other - Specify
SERVICES PROVIDED:

Arts and Culture Capacity Building Children and Youth Services Civil Rights, Social Action, Advocacy Community Improvement Community and Juvenile Justice Domestic Violence Educational Service Emergency Assistance Employment and Training Environmental Services Health Related Housing, Shelter , Homelessness Legal Assistance Mental Health Philanthropic Professional Association Public Acton Group Public Safety Religious Recreation Substance use
Other:
TARGET POPULATION:

Youth 5 to 16 years old Adults Seniors (55 & up) Infants/Toddlers/Pre K Special Needs Special Ethnic Group
Other:
Thank you for taking the time to complete the application
Should be Empty: