Name of Organization

Question Title

* 1. Name of Organization

Contact Person Name

Question Title

* 2. Contact Person Name

Contact Person's title within organization

Question Title

* 3. Contact Person's title within organization

Mailing Address of Organization

Question Title

* 4. Mailing Address of Organization

Contact Person Email Address

Question Title

* 5. Contact Person Email Address

Contact Person Phone Number

Question Title

* 6. Contact Person Phone Number

Organization's Website (if applicable)

Question Title

* 7. Organization's Website (if applicable)

Amount Requested

Question Title

* 8. Amount Requested

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

Question Title

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

Which focus area does the program fit into?

Question Title

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

Describe the program for which you are seeking funding.

Question Title

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

How many individuals will be impacted by this funding?

Question Title

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

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

Question Title

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

How will the funds specifically be used?

Question Title

* 14. How will the funds specifically be used?

What other funding sources do you have for this program?

Question Title

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

What is the sustainability of this program after the use of this grant?

Question Title

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

T