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Organization Details

Organization Name:

Address:

Address con't:

City:

State:

Zipcode:

Telephone:

Fax:

Website:

Organization Focus:

Organization Mission Statement:

Year organization was established:

Approximate number of staff:

Approximate number of Volunteers:

Total annual budget:

Grant Amount Requested:

Is your organization affiliated with any national organizations? YesNo

If yes, does your organization receive any funding from the organization? YesNo

Top 3 Sources of Funding

Funding Source 1:

Funding Source 2:

Funding Source 3:

Organization Director

Director First Name:

Director Last Name:

Director Telephone:

Director Email:

Contact Person

Contact First Name:

Contact Last Name:

Contact Telephone:

Contact Email: (this will be login username):