Required Information Sheet

Date of Application: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2006 2007

Have you ever applied to the foundation before: No Yes

Organization Name:

Address:

City:

State:

Zip Code:

Telephone Number:

Fax Number:

Email Address:

Person to contact regarding this proposal:

Project Budget:

Amount Requested:

Type of Request (Please select appropriate category):

Start-Up General Support Project

Category (Please check one):

Arts Conservation Education

Health and Welfare Public Affairs Science

Total Organization Budget:

Budget Last Year:

Please provide a summary of your organization's mission (1-3 sentences):

Summarize your project or operating request: (1-3 sentences):

What population do you server? What geographic focus? (1-3 sentences):

Upon clicking Submit your default email client will open a message containing the information provided in the above form.

Please review the information carefully as your proposal will be reviewed based in part to the information provided above.

Incomplete proposals will not be reviewed.

To complete your application please attach, fax or mail the following information:

1) Letter: A brief (up to 2 pages) executive summary of the grant request, in letter form.

2) 501(c)(3) form from the Internal Revenue Service.

3) Board of Directors and Funding Sources: Please list your organization's board of directors, as well as your other funding sources for this request. Please list whether this funding is committed, pending or received.

4) Supporting Documentation: 2-3 items of current printed materials, such as annual reports, media clippings, testimonial letters, brochures, etc.