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* 1. Name of Organization

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* 2. Contact Person Name

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* 3. Contact Person's title within organization

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* 4. Mailing Address of Organization

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* 5. Contact Person Email Address

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* 6. Contact Person Phone Number

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* 7. Organization's Website (if applicable)

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* 8. Amount Requested

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* 9. Is the Organization a non-profit with a 501(c)3 designation?

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* 10. Which focus area does the program fit into?

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* 11. Describe the program for which you are seeking funding.

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* 12. How many individuals will be impacted by this funding?

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* 13. What outcomes will you use to measure success of this program?

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* 14. How will the funds specifically be used?

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* 15. What other funding sources do you have for this program?

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* 16. What is the sustainability of this program after the use of this grant?

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