Initial Inquiry Form

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Organization Information
Organization Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Fax
Website

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Financial Information
Annual Operating Budget*
Fiscal Year End Month*
Number of Full Time Employees*
Number of Part Time Employees*
Proposal Information
Project Name
Purpose of Project*
Estimated Project Start Date*
MM slash DD slash YYYY
Estimated Project End Date*
MM slash DD slash YYYY
Total Project Cost*
Amount Requested*
Population and Number of people served by this project*
Project Description
Describe the project for which you are requesting funds*
Outcomes
Indicate the project's specific, measurable outcomes expected from this project and how your organization will measure those outcomes*
I certify, to the best of my knowledge, that:
1. The tax-exempt status of this Organization is still in effect,
2. This Organization does not support or engage in any terrorist activity, and
3. If a grant is awarded to this Organization, the proceeds of that grant will not be distributed to or used to benefit any organization or individual supporting or engaged in terrorism or used for any other unlawful purpose.
ESIGN Disclosure
Section 101 of the ESIGN Act, sub-section (b), preserves the rights of individuals to NOT USE electronic signatures. Here the law provides that individuals reserve the right to use a paper signature. Sub-section (c) is in direct support of (b) by requiring a “Consumer Disclosure” that the signatory has consented to use an electronic format.
Signature:*
- I consent to using an eSignature
- I do not consent to an eSignature, I prefer a paper signature
Signature
Name of person signing*
Title of person signing*

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Organization Information

Contact Information

Executive Director

Board Chair

Financial Information

Proposal Information

Project Description

Outcomes

I certify, to the best of my knowledge, that: