Online Grant Application

Name of Organization: *

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Website:

Contact Person: *

Title: *

Phone 1: *

Phone 2:

E-mail Address: *

 

Briefly describe the history, mission and general information about your organization (100 words or less). *

 

PURPOSE OF REQUEST

What is your request? *

Amount requested: *

Is this part of a multi-year request? *
YesNo

If so, please explain:

If the program is on-going, how will it be sustained?

 

Briefly discuss your program (300 words or less). *
If more than one request, use separate application form for each request. You may upload two-to-three attached pages of photos, layouts, descriptions to help clarify your request. No more than three pages will be accepted. Please include the following in your discussion: what needs will the program address? Who will the program serve? How many people will benefit from this program? Why do you feel this program is important to the community?

Upload supporting documents here (use zipped folder for multiple files):

 

How does your program meet the mission of The Blazer Foundation? *

How will you measure the program’s success? *

 

FINANCIAL DISCUSSION OF THE PROGRAM

Provide a brief financial overview of your organization. Include funding sources and a recent balance sheet. *

Upload balance sheet here:

 

Provide an income and expense budget for this program. *

Upload budget document here:

 

Include current funding sources for this project. *

Staff/administrative costs (dollars and as percentage of budget): *

Have you requested funds from any other sources for the same purpose? * YesNo

If you have requested funds from any other sources, please list all to whom you have applied.

When are the funds needed? *

What is the value of your endowment? *

What is your policy regarding annual expenditures from the endowment? *

 

ADDITIONAL INFORMATION

Please provide a list of your agency’s board of directors. *

Please attach a copy of your 501(C)(3) tax exempt letter from the IRS.

 

If a site visit or presentation to The Blazer Foundation Board of Directors is required, who is the contact to arrange these?

Name:

Phone:

E-mail Address:

 

SIGN & SUBMIT

Applicant’s Full Name / Title: *

Date: *

 

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