GRANT APPLICATION FORM


Date of Application:    Example: 05/30/2009
Name of Organization:    (Should be same as on IRS determination letter)
Tax Exempt Status #:
Year Founded:
Current Operating Budget:
Executive Director:
Executive Phone Number:
Contact Person:    (If different from executive director)
Title:
Contact Phone Number:    Example: 000-000-0000
Street Address:
City:
State:
Zip Code:
Fax Number:
Email Address:
Project Name:
Purpose of Grant:
Project Dates:    Example: 05/30/2009 - 06/30/2009
Total Project Cost:
Amount Requested:
Geographic Area Served:
Request Type: Grant Renewal
New Grant Request