* 1. Name of Organization

* 2. Contact Person Name

* 3. Contact Person's title within organization

* 4. Mailing Address of Organization

* 5. Contact Person Email Address

* 6. Contact Person Phone Number

* 7. Organization's Website (if applicable)

* 8. Amount Requested

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

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

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

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

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

* 14. How will the funds specifically be used?

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

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

T