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Step 1 of 5 - Contact Information
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Executive Summary
Organization Name
*
Project/Activity Name
*
One sentence summary of the project/activity
*
Why is there a community need?
*
Who and how many people (target population, age, gender, ethnicity, other)
*
What services are provided?
*
When (timeframe)
*
Where (location of the work)
*
What do you hope to accomplish (outcomes)?
*
How does this request meet this funder's priorities?
*
Total cost of this effort:
*
Amount requested from this funder:
*
Signature of CEO
*
By typing my name below, I confirm that I am an authorized by my organization to submit this application, and that the information provided is true and correct to the best of my knowledge.
Signature of a board representative (chair or president)
*
By typing my name below, I confirm that I am an authorized by my organization to submit this application, and that the information provided is true and correct to the best of my knowledge.
Financial summary of your organization's most recently completed fiscal year
*
including the original budget and the actual revenue and expenses for that year.
Drop files here or
Accepted file types: jpg, jpeg, png, pdf, docx, xls.
If you are a 501(c)(3) organization, a copy of the IRS determination letter
advising that your organization is exempt from taxes under Section 501(c)(3) of the IRS code, and that the organization is not a private foundation as defined in Section 509(a).
Drop files here or
Accepted file types: jpg, jpeg, png, pdf.
List of the organization's Board of Directors
*
with their affiliations.
Organization Information
Name of Organization
*
Organization Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Phone
*
Fax
Your Email
*
Enter Email
Confirm Email
Name of Chief Executive
*
First
Last
Title
*
9-digit Federal Employer ID:
*
Year incorporated:
*
Information for This Request
Name of this program or project:
*
Name of contact person:
*
First
Last
Phone
*
Type:
*
Capital
Endowment
Program/Project
General Support
Other (describe)
If "Other" please explain:
Date funds needed by:
*
Date Format: MM slash DD slash YYYY
Date by which funds will be spent:
*
Date Format: MM slash DD slash YYYY
Rochester Area Logic Model
Inputs
*
($'s, staff, volunteers, materials and other resources requitred) Quantify inputs whereer possible (e.g. "2.5 FTE social workers, 270 volunteer hours")
Activities
*
(What the program does with the inputs to achieve its outcomes) Activities should be quantified (e.g. "2 support groups/10 moms ea./2hrs/wk for 4 mos.")
Projected Outcomes - Short Term
*
(Effects on knowledge, attitudes, skills, behavior, condition or status during or after the program/project) Place a "*" next to those to be measured.
Projected Outcomes - Long Term
*
(Effects on knowledge, attitudes, skills, behavior, condition or status during or after the program/project) Place a "*" next to those to be measured.
Rationale
Need/demand
*
present in bulleted format, and where possible, include local statistics, community priorities, etc. 1. Summarize the need for your planned work. 2. Summarize customer demand for this work.
Accepted file types: jpg, jpeg, png, pdf, docx, xls.
For each outcome you will track, as identified in your logic model, indicate how you will know if you succeed in achieving it, using the following format:
Outcomes
*
Indicators/Measures
*
What will you measure to know if you reach your outcomes?
Targets/Performance
*
Standards/Projected levels of success. What ill tell you that you have achieved your outcomes?
When will these targets be achieved?
*
Date Format: MM slash DD slash YYYY
Agreement
*
by submitting this application, you understand that this does not guarantee funding from this organization.
I agree to the terms of service
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