Community Funds Request

Date of request * +

Needed by date * +

Amount of request *

Organization Name

+-

Contact Name *

Contact's Email *

Phone Number * 🛈

What type of request is this: *

One time

New ongoing

Annual Renewal

Is this request also being submitted to other grant organizations? *

If yes, which organizations have you applied?

Please describe the equipment / project / program (attach copies of invoices, brochures, catalogs, etc.). Please include applicable information to support the requests such as: the impact of the request, the planned results, support funding for equipment, numbers served, impact on core measures and/or safety goals. *

Who is the Vendor?

Proposed purchase date +

Please upload any documents (quotes, receipts, etc.) to support your request.

Signature. I certify that all information is accurate to the best of my knowledge *

clear

Date * +