GRANT REQUEST FORM 2013 MAYOR’S CHARITY BALL
Organization Address
City
State
ZIP
_________________________________ Phone
__________________________________________ Fax
_________________________________ __________________________________________ Contact Person Title _________________________________ __________________________________________ Email Address Website _________________________________ __________________________________________ Executive Director (if different from above) Email Address Mission of Organization___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Project for which funding is requested ________________________________ __________________________________________ Amount Requested Total Cost of Project
________________________________
__________________________________________ Signature of President/Director Signature of Board Chair Of 501c3 __________________________________________ Printed Name of Board Chair