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Application For Donation For Organization/Agency

* denotes a required field.
Name Of Organization *:
Address1 *:
Address2:
City *:
State *:
Zip *:
Phone Number *:
Fax Number:
Contact Person *:
Email Address*:
Website:


Please describe your organization(check all that apply).
    If other, please describe


If the organization requesting funding is exempt from payment of income tax, please forward a copy of the organization's letter (Form 501(c)3) from the Internal Revenue Service.



What is the primary overall mission of this organization?



What is the primary source of funding for this organization?



Please check all counties to which this organization provides services and list, where possible, the number of individuals, families or groups served in the counties within the last year:

   
   
   
   
   


Does your agency serve outside any of the above listed counties?

    If yes, please provide additional information on what areas this organization     serves and how this organization selects its beneficiaries:

    


Please state the specific purpose of the Organization/Agency request for funds from Washington Electric Foundation: (Include amount requested and specifics of how funds will be used. Include applicable cost estimates for contract work or equipment purchases and when funds are needed - attach additional pages if necessary)



List other sources of funding that have been requested for the use as described above and what requests for funding have been secured:



How are the organizations programs measured for effectiveness?



Please list three references:
Name(1):    Phone:  
Adress:  
City:     State:     Zip Code:  
Name(2):    Phone:  
Adress:  
City:     State:     Zip Code:  
Name(3):    Phone:  
Adress:  
City:     State:     Zip Code:  


The information contained in this statement is for the purpose of obtaining funding from the Washington Electric Trust on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding to grant funding, and each undersigned represents and warrants that the information provided is true and complete and that the Washington Electric Trust may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Washington Electric Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.


Please click this checkbox to sign this form:
Date: 9/7/2008 11:53:09 PM


  

 
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