* GRANT * APPLICATION *

Contact Information
Full Legal Organization Name
Street Address
City
State
Zip Code
Organization Website
Organization President / Executive Director
Title
Phone Number
E-Mail Address
Contact Person
Title
Phone Number
E-Mail Address

* GRANT * APPLICATION *

Organization Information
501(c)(3)?

Yes No
Year Established
Fiscal sponsor name
Fiscal sponsor address
Total Organization Budget
Total # of Board Members
Total # of Staff
Total # of Volunteers
Organizational Mission Statements
Brief Description of Organization
Population Served

* GRANT * APPLICATION *

Proposal Request
Program / Project Name
Total Program Budget
Requested Amount
Percent of Total Budget
Type of Request
Grant Period From

Month Day Year
Grant Period To

Month Day Year
Multi-Year?

Yes No
Geographic Area Served
Priority funding areas
Most recent grants received from this funder:
Amount (1)
Date (1)

Month Day Year
Amount (2)
Date (2)

Month Day Year
Should be Empty: