Grant Application Form

Legal name of organisation:  *

IRS Tax Exempt Status:  *

Please note: A copy of your IRS and Franchise Tax Board determination letter confirming your status as a tax exempt, not-for-profit organization must accompany this application)  *

EIN (Tax Identification Number):  *

Grant Request Amount:  *

Organization’s Mailing Address:  *

Name and title of person of primary contact for grant application

Primary contact’s telephone:  *

Primary contact’s email address:  *

Fax:  *

Web address:  *

Title of Project

Briefly explain in one paragraph the specific purpose for which funds are requested, how the funds will be spent and the anticipated results of your program.  *

BOARD OF DIRECTORS INFORMATION

Number of persons serving on the board:  *

(please attach list, with brief description of qualifications)  *

Number of directors making a personal contribution to the organization during the past 12 months:  *

Total contributions received from directors in the last fiscal year:  *

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