Only to be submitted if requested by Marian Spicer, Executive Director
Please call (937) 497-7800 before you send.
* Indicates Required Field

* Applicant Organization
* If a grant is approved, make check payable to: EIN#
* Mailing Address:
* City:
* State:
* Zip Code:
* Phone:
* Contact Person:
Direct Phone:
* Email:
* Organization's Major Funding Sources: (ex. annual campaign, fundraiser, taxes, United Way, etc.)
Does your organization have an IRS 501(c) (3) tax exemption letter?
* Program/Project/Equipment Name:
* Amount requested:
* Total Program/Project budget:
* Brief demographic description of population (including number) served by this program/project:
* PROJECT SUMMARY: Please summarize your proposal in the space provided: Include brief, specific, information about the what, when, why and how of your project. No attachments will be considered at this stage in the process.
* Chief Executive Officer/Authorized Official:
* Date: