Initial Inquiry Form For the fastest response, please complete this online form.If you prefer printing and mailing your application, download the PDF version of the form > 1Step 12Step 23Step 3 Organization InformationOrganization Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*FaxWebsite Contact InformationName*Title*Phone*FaxEmail*Executive DirectorName*Title*Phone*FaxEmail*Board ChairName*Title*Phone*FaxEmail* Financial InformationAnnual Operating Budget*Fiscal Year End Month*Number of Full Time Employees*Number of Part Time Employees*Proposal InformationProject NamePurpose 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 DescriptionDescribe the project for which you are requesting funds*OutcomesIndicate 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 DisclosureSection 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 SignatureName of person signing*Title of person signing*