Grant Request

GRANT APPLICATION

TOPUCU PROGRAM GRANT APPLICATION

* Indicates required field

Date of Application *

Organization Name *

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Fax Number *

Federal Tax Identification Number *

Contact Person *

Title *

Person Completing Application *

Direct Phone *

Email Address *

Are you a 501(C)3 Organization? *

Organizational Background Information

A. Mission of Organization *

B. Population Served *

C. Services Provided *

D. Approximate number of clients served annually (if applicable) *

E. What is your geographic service area? *

F. What is your gross annual revenue? *

G. Year Incorporated *

H. State of Incorporation *

I. Number of Total Employees: *

J. Name of any Affiliate, Subsidiary, or Parent Organization *

K. Executive Director/President *

L. Board Chairperson *

Program Request

A. How many programs are you requesting? *

B. Briefly describe the format and overview of how you would like to incorporate the program into your current operations? *

C. Will you need facilitator training? *

D. When would you like to start the program? *

E. Do you have funds for the program? If so, how much? *

Financial Information

A. Fiscal or accounting year ends *

B. Staff member responsible for financial reporting and management *

C. Financial statements are prepared by *

D. Board Treasurer *

E. Does the Board have a Finance Committee? *

Yes No

Certification of Application

Name *

First

Last

Date *

Send Application