Please have a copy of the application in PDF format to help guide you as you're filling out this survey, as some information has been omitted for length.

Also, note that this is a two-step application process. First, complete the survey below. Next, complete the additional information requested on pages 6 and 7 of the PDF application. This information will need to be submitted via email to kelly@ohiobeverage.com. Please be sure to initial each section and include pages 6 and 7 as an attachment with your email. This is a rolling application process – there is no deadline to apply.

*required fields

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* 1. Date: *

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* 2. Legal Name of Organization: *

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* 3. Contact Person and Title: *

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* 4. Street: *

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* 5. City: *

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* 6. State: *

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* 7. Zip: *

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* 8. Phone: *

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* 9. Email: *

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* 10. Is the organization a 501(c)(3) or a state or local governmental entity that will use the grant funds for a charitable purpose? *

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* 11. EIN #: *

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* 12. Year Founded: *

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* 13. Organization Type: *

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* 14. If other, please explain:

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* 15. Mission Statement (2000 character maximum): *

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* 16. Geographic Area Served (specific to this proposal): *

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* 17. Number of Full-Time Employees:

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* 18. Number of Part-Time Employees:

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* 19. Organization History (2000 character maximum): *

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* 20. Executive Director of Organization: *

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* 21. Executive Director’s Email: *

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* 22. Project/Program Title: *

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* 23. Amount Requested: *

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* 24. Project/Program Status (please check an option below): *

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* 25. Project/Program Start Date: *

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* 26. Project/Program End Date: *

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* 27. Project/Program Description (6400 characters maximum): *

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* 28. Experience with this type of project/program (2000 characters maximum): *

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* 29. Salaries and Benefits (Please complete in US dollars): *

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* 30. Admin Expenses (Please complete in US dollars): *

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* 31. Program Costs (Please complete in US dollars):*

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* 32. Other (Please complete in US dollars):

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* 33. Please provide additional context around budget expenses (2000 character max):*

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* 34. Primary Goal or Objective of Project/Program (500 character maximum): *

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* 35. Success Metric for Primary Goal or Objective (500 character maximum): *

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* 36. Direct Beneficiary Group (500 character maximum): *

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* 37. Number of Direct Beneficiaries: *

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* 38. Overall Expected Outcomes (2000 character maximum): *

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