NAME AND ADDRESS OF ORGANIZATION ORGANIZATION EXECUTIVES PURPOSE OF ORGANIZATION PURPOSE OF REQUEST TOTAL COST OF PROJECT AMOUNT REQUESTED FIVE RECENT CONTRIBUTORS ANY GOVERNMENT OR UNITED WAY SUPPORT NAMES TITLES AND SALARIES OF TOP THREE NUMBER OF EMPLOYEES NUMBER OF VOLUTEERS ESTIMATED OPERATING COSTS APPROVAL OF EXPENDITURES AGE OF ORGANIZATION MEMBERS/CLIENTS SERVED ANNUALLY SIGNATURE OF RESPONSIBLE PARTY