ࡱ> DFC O)bjbjMFMF B/,/,O!QQQQQeeeeey,eACCCCCCNVCQCQQXRQQAAQQτ[{ae<n0F F Q :    Granville Foundation 2012 GRANT APPLICATION FORM Organization Legal Name: ____________________________________________________ Organization Mailing Address: ________________________________________________ Contact Name: _____________________________________________________________ Contact E-mail Address: _____________________________________________________ 1. Is your organization a non-profit legal entity with 501(c)(3) status? c Yes c No 2. Does your organization have paid staff? c Yes c No If yes, how many full-time equivalent? __________ 3. Does your organization utilize volunteers? c Yes c No f yes, how many full-time equivalent? __________ 4. Approximate number of individuals served annually by your organization: __________ 5. Will this grant involve the need for additional employees? c Yes c No If yes, how many? __________ 6. Has your organization previously applied for a Granville Foundation grant? c Yes c No 7. Has your organization previously received a Granville Foundation grant c Yes c No If yes, when? __________ 8. Name of project or program for which you are seeking Granville Foundation support: ___________________________________________________________________ 9. Describe the purpose, goal(s), and objective(s) of this project in 1,000 words or less: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ (Insert additional pages if more space is required) 10. Amount of financial support you require from the Granville Foundation: ___________ 11. Estimated total cost of project or program from all sources: ______________ 12. If the full amount of your request for funding cannot be granted, can your organization accept partial funding and still meet the goals of the project? c Yes c No Please explain: ________________________________________________________ _____________________________________________________________________ 13. Are you seeking support for a new or established program or project ? c New c Established If established, how long has the project or program existed?____________________ 14. Have you been refused any funding for this request from the Granville Foundation or other source? c Yes c No Please explain: ________________________________________________________ _____________________________________________________________________ 15. If this is an ongoing project, how will it be funded in the future? _____________________________________________________________________ _____________________________________________________________________ 16. Will you collaborate on this project or program with other organizations? c Yes c No If yes, which ones? _________________________________________________________ _________________________________________________________________________ 17. What outcomes must be achieved to classify this project or program as a success? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 18. Why is this project or program important to Granville; how will it improve our quality-of-life? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 19. Provide any additional information that you wish to include that is pertinent to this grant request: ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 20. Project or Program Personnel a: _______ Number of full-time equivalent employees b: _______ Number of full-time equivalent consultants c: _______ Number of full-time equivalent volunteers 21. Project or Program Expenditures: Grand total $_____________ a: ______ Employee labor b: _______Consultant labor c: _______Honoraria d: _______Supplies and materials e: _______Transportation f: _______ Per diem food and lodging g: _______Facility rentals h:_______ Equipment rentals i: _______ Equipment purchases (Explain and justify) __________________________ _____________________________________________________________________ _____________________________________________________________________ 22. Project or Program Funding: Grand total $ _________________ a: ______ Granville Foundation grant b: _______Other foundation grants c: _______ Federal or state government grants and/or contracts d: _______Own-source revenue e: _______Public contributions or donations solicited for this project f: _______ Loans g: _______All other CERTIFICATION OF INFORMATION: Name of organization President (or equivalent): ___________________________________ Signature of organization President (or equivalent) ________________________________ Date: ___________ -/KO       R Y  % _ ` a c d i j k = ? @ E F G e l ĶĶĶĶĶĶĶh"OJQJmH sH h"h"CJOJQJmH sH h"CJOJQJmH sH h"CJmH sH #hh"5CJOJQJmH sH h@QB* CJ(phh@QB* CJphh@QB* phh@Q<  -/KMO R >]^`>gd">]^`>gd"$$ >^`>a$gd"$a$R  e  gh]^gd" >^`>gd"$P>^]P^`>gd">]^`>gd" L]^`Lgd">]^`>gd"l  <=%$%a%' '$'%'b's()N)O)ννޠνννޱννޱޱh"OJQJ!h">*CJOJQJaJmH sH h"CJOJQJaJ!h">*CJOJQJaJmH sH h"CJOJQJaJmH sH h"CJOJQJaJmH sH h"h"CJOJQJmH sH /\de<=3 ps]s^gd" ]^`gd" ]^gd"v>]v^`>gd" v]v^v]v^gd" >^`>gd" >^`>gd" 8"9":""Y$Z$[$%%' 's((( ]gd"2v>]2^v`>gd"$.v>].^v`>gd".].^gd".].^`gd".].^gd"s]s^`gd"(O)/ =!n"n#n$n%666666666vvvvvvvvv66666686666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH T`T Default*$1$$CJKHPJ^J_H9aJmH sH tH9JA J Absatz-StandardschriftartViV 0 Table Normal :V 44 la (k ( 0No List NN Heading x$OJQJCJPJ^JaJ6B@6 Text body x(/( List^JH""H Caption xx $CJ6^JaJ].2. 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