Name of requesting entity:
Mailing address:
Street:
City:
State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--District of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands
Zip:
Telephone number:
Website (if any):
Employer Identification Number (EIN): Note: This number will be used to verify applicant’s status as a qualified 501(c)(3) organization.
Brief description of entity’s charitable activities:
Brief description of the specific project for which you are requesting funding or volunteer assistance:
Dollar amount of financial assistance you are requesting ($):
Number of volunteers you are requesting:
Total number of volunteer hours you are requesting:
Number of workdays you are requesting:
Number of beneficiaries:
Description of project beneficiaries:
Coldwell Banker or company contact:
