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* 1. Please provide:

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* 2. Is your organization a qualified 501 (c) (3) organization in good standing and a tax exempt governmental unit, or are you working with a qualified fiscal agent/sponsor?

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* 3. How long have you been an organization?

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* 4. How long has your current CEO/Executive Director/President been in his/her position?

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* 5. Does your project intend to support health care services or health-related purposes to vulnerable populations in California?

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* 6. Which counties?
*Check all that apply

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* 7. Does your project relate to one of our focus areas (visit UniHealthfoundation.org):

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* 8. Is your anticipated request specific to any of the following:
*Check all that apply

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* 9. Have you applied for support in the last 12 months and is this a new LOI for a different request?

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* 10. If you have received a grant from the Foundation in the last three years, will the final report be submitted before the grant period begins for your current request?

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* 11. What is your organization's approximate annual operating budget?

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* 12. What is your anticipated request amount?

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* 13. What is the expected grant term?

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* 14. Briefly summarize the nature of the request.

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* 15. Additional Comments:

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