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Applicant Organization’s Name:

Date incorporated as a 501 (c) 3: OR Applied for 501 (c) 3; not awarded yet

Program or Project Name:

Executive Director (if none, Board President):

Program or Project Director:

Address:            State:

City:                 Zip:

Phone:      Fax:      E-Mail:

Web Page:

Tax ID Number:

Applicant Organization’s Mission (no more than 100 words):

Program / Project Summary and/or event information (no more than 100 words):

Problem or need the organization wants to address and/or how profits from this grant will be directed (no more than 100 words):

Date(s) of project/event/program:

Please let us know of any successes or accomplishments you wish to bring to our attention:

Who else is providing funding for this event/program?

Amount Requested:            Geographic Service Area:

Applicant Organization’s Area of Service / Focus (check all that apply):
Arts & Humanities Education Science Human Services
Medical/Health Conservation Community Development Other (explain)

Attachment Checklist:
Names / pertinent staff: 501 (c) 3 verification: List of Board Members:
Program / project budget: Brochure, invitation, etc: Last and this fiscal year’s financial statements:

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