Grant Application Form Step 1 of 3 33% Organizational InformationOrganization Name* Federal ID Number* Date MM slash DD slash YYYY Business Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address Is your mailing address different than your business address? Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Organization Phone*Website* Chief Executive Officer* Phone*Email* Project Contact Person* Phone*Email* Project Contact Person Title* Current tax-exempt status*(If exempt under another organization, include evidence from IRS of that exemption and the relationship between the exempt organization and the applicant organization.)501©(3) and (509)(a)OtherAdditional Tax DocumentsMax. file size: 100 MB.Current year's Financial Statements(Preferably audited)Max. file size: 100 MB.Last year's Financial Statements(Preferably audited)Max. file size: 100 MB.Purpose of Grant*Grant Amount Requested* Date Needed* MM slash DD slash YYYY Current Total Project/Program Budget* Current Total Organization Budget* Most recent Annual Report(if published)Max. file size: 1 MB.Please provide any recent publications, news articles or other relevant materials about your organization or the funded project (please be selective, providing a maximum of five)Additional Information #1Max. file size: 100 MB.Additional Information #2Max. file size: 100 MB.Additional Information #3Max. file size: 100 MB.Additional Information #4Max. file size: 100 MB.Additional Information #5Max. file size: 100 MB.Medical documentation to support disability(s)(if applicable)Max. file size: 100 MB.Please provide a list of your top three funders to the project or program.List FundersPlease list your board members and their relevant experience.Number of board members*0123456789101112131415List your board members and their relevant experience:*Or you can upload a profiles/bios document here.Max. file size: 1 MB. Information About Project for Which Funds are Requested Please submit a 2-4 page narrative responding to the requested proposal information below. Total narrative length should NOT exceed 4 pages (10-12 point font). Please be brief and concise. About your Organization Organization’s mission Staff size Current programs or services provided Description of project /program Description of project/program Timeline of project/program Who are the key decision-makers involved in this project/program? How do their backgrounds contribute to the project/program? Geographic area to be served by project Population (number and groups) to be served by project Total Project cost and amount requested Goals of project program Major goals of project/program How will these goals be met? Project/Program Evaluation How will you measure & document the results of the funds awarded? Funding/Resources Amount and sources of approved contributions/pledges for project to date Amount and sources of requested or pending contributions/pledges for project to date Please Upload Your Response*Max. file size: 100 MB. Terms I certify that the above information is correct and that the governing board of this organization has approved submitting this grant application to The Shapira Foundation. I further understand that if a grant is awarded, I will be expected to document the results of the effectiveness of projects or programs and required to complete annual results reporting. Signature of Chief Executive Officer (or a person authorized to sign on behalf of organization)Name* Title* Date of Signature* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
