Name of Organization/Business applying for funds
Name of person completing this application
Contact information for questions and follow up: Phone
Status of your organization/business
Profit
Non-Profit
Non-Profit IRS code
(Enter N/A if 'Profit' business)
Amount of funding requested
Would partial funding be acceptable?
Yes
No
Describe the purpose of this request (what type of purchase/project)
Please list other sources of funding
Number of people in our area who will be affected by this purchase/project
Projected date that equipment will be in use or project will be completed
Why do you feel this purchase/project is important to the present and/or future health of the citizens of this area?
Supporting Documentation
Supporting Documentation 2
Supporting Documentation 3
SUBMIT
