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* 1. First and Last Name

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* 2. Email

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* 3. Organization

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* 4. Organization Budget (approximate)

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* 5. Geography Served (select all that apply)

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* 7. Indicate your preference for how you would prefer to receive funding, if awarded:

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* 8. Please indicate the type of expense(s) for which you are seeking emergency financial assistance. Select one or more that are covered under your request.

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* 9. Please list the names and amounts of emergency funding you have secured or anticipate receiving from foundations or relief funds over the next three months (ex. ABC Fund - $20,000):

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* 10. Please indicate the amount of funding you are requesting from us ($5,000 - $50,000):

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* 11. Optional - please include any additional information you would like us to know about the short-term, immediate expense(s) for your request (max of 500 characters).

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