Committed to Florence
Committed to Pinal County

Application Form

Most fields are required. For any section that does not apply to your organization, please mark "N/A."

Grant Application

Organization Name:

Project Name (if any):

Organizational Information:

1. Organization's History:

2. Organizational Goals and Objectives (short-term and/or long-term):

3. Programs and Services (briefly describe your organization's programs and services):

4. Organizational Structure (board, staff, volunteers):

Proposal Information:

5. Description of Program/Project:

6. Description of Need (What is the issue you plan to address? What is your approach?):

7. Specific Activities (Include information about service delivery and/or timeline.):

8. Objectives and Goals for this Request (How will this grant strengthen the organization, address the issues, make improvements, or achieve success?):

9. Evaluation (What are the anticipated outcomes and how will you know if you are successful?):

10. Other (Use this space to provide any additional information that you feel would be relevant to this grant request that is not covered in the sections above.):

Budget Information:

Provide an explanation/justification of funding request and the amount

Grant Application Cover Sheet

Date of Application:

Organization Information

Name of organization		Legal name, if different
Address	City, State, Zip	Employer Identification Number (EIN)
Phone	Fax	Website
Name of top paid staff	Title	Phone	Email
Name of contact person regarding this application	Title	Phone	Email

Is your organization an IRS 501(c)(3) not-for-profit? Yes No
If no, is your organization a public agency/unit of government? Yes No

Fiscal agent's EIN number

Proposal Information

Please give a 2-3 sentence summary of request:

Population Served:

Geographic area served:

Interest area of grant (check one)

Education	Environment
Cultural Heritage, Art & Tourism	Health & Wellness
Community & Economic Development

Funds are being requested for (check one)

General operating support	Start-up costs	Capital
Project/program support	Technical assistance	Other (list)

Project dates (if applicable):

Fiscal year end:

Budget

Total annual organization budget:	$
Total project budget (for support other than general operating):	$

Authorization

Name and title of top paid staff or board chair: