Applications and Reporting

Name (required):

Organization Name:

Email (required):

Address:

City:

State:

Zip:

Are you a 501 (c)(3)?:
YesNo
Day Phone:

Evening Phone:

What is/are the purpose/s of your organization?*

Do any other groups or organizations provide the same service as your organization? Explain.*:

If awarded a grant, what specific items or programs would the grant support? Please be specific.*

What geographic area do you serve?:**

How many people do you serve?:*

Please fill in the following letters to cut back on spam: