Form

Organization Name*

Address*

City*

State*

Zip Code*

Website

Year Founded*

501(c)(3)? *Not Required*

Yes No

Fiscal Sponsor?*

Yes No

President/Exec. Dir.

Phone #

Email

Organization Mission Statement (100 words or less):

Targeted Geographic Area

Total Program Budget $*

I hereby verify that the information provided is accurate and honest to the best of my knowledge.

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