Date of Application

Name of Applicant Organization

Payable To (if different than Organization Name above)

Mailing Address of Organization *

Name (Applicant) *

Area Code

Phone Number (Applicant)*

Email (Applicant)

What is your involvement with the organization? *

Please provide a general description of your organization *

Please provide a description of the project for which you would like to receive a donation *

How will your project directly benefit the local community? *

How many people will your project directly impact and how will they be impacted? *