Complete and submit the form below.
Chief Executive Officer (CEO)/Executive Director:
Contact Person for this Application, if different from CEO/Executive Director.
Period Time in which funds will be spent:
Is your organization classified as a charitable organization under Section 501(c)(3)?
Is your organization classified as an organization to which contributions may be deducted under Section 170(c)(1) of the Internal Revenue Code?
Specific Purpose for which Grant Funds are Requested:
Anticipated Outcome of Project:
Brief Statement of your Organization's History, Purpose and Services: