Rotary Club of Jeffersonville
Grant Application
| Organization Name: _______________________________________________ | ||
| Address: _______________________________________________ | ||
| City: ____________________ | State:_________ 
|
Zip:_________ |
| Contact Person: ________________________________ | Phone:_______________ | |
| Date of Project: | ______________ |
Amount Requested:
|
_______________ |
| Does your agency receive any funding through an affiliation with a national Organization? | |||
| YES _____ NO _____ | If yes, explain: _____________________________________________ | ||
| ________________________________________________________________________________________ | |||
| If your organization has received funding from this Rotary Club when was the date? ______________________ | |||
| Purpose / Use of funds for current request: | ______________________________________________ | ||
| ________________________________________________________________________________________ | |||
| ________________________________________________________________________________________ | |||
| Number of Clark County/Southern Indiana residents to be served by request (List number, ages, etc.) | |||
| ________________________________________________________________________________________ | |||
| List other funding sources for the project: | ______________________________________________ | ||
| ________________________________________________________________________________________ | |||
| Does your agency receive any funding through the Metro United Way? __________ | |||
| How will this project be impacted should Rotary choose to not support it? | |||
| ________________________________________________________________________________________ | |||
| Signature of Applicant: | __________________________________ | Date: ___________ | |
|
|
|||
| Evaluation Review (Rotary Club use only) Comments: | |||
| ________________________________________________________________________________________ | |||
| ________________________________________________________________________________________ | |||
| ________________________________________________________________________________________ | |||
| Signature of Board President: | _________________________ | Date:_______ | |
| (Feel free to extend your comments onto additional sheets) | |||