GRANT APPLICATION FORM Organization Name Organization's mission statement Year founded Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Website http:// Email Executive Director First Name Last Name Executive Director's Email Application contact person and title (if different) First Name Last Name Geographic areas served by your organization: Local International Indicate the one program area that best describes your organization’s focus: Peace & conflict resolution Disease prevention & treatment Water & sanitation Maternal & child health Basic education & literacy Economic & community development Environment & sustainability Other Please describe: Name of Rotary Club of Boulder Flatirons member who offered to sponsor this application First Name Last Name This request is for: equipment/materials specific project/program support Project/program name, or activity for which funding is being sought: If you are applying for support for a particular program, when did you begin operating that program? (Check one) This request is not for support of a particular program. This program began operating in the year. This is the first year of this program. Dollar amount requested ($3,000 max): * $ Budget for total expenses for proposed project/program or equipment/materials: $ Duration of the project/program for which funding is being sought (If equipment/materials, tell when you plan to acquire it) : Please write a brief statement that summarizes the purpose of this grant request in the space below, and include who would benefit, and how. Thank you!
