CCBNA

Grant Application

Please Fill Out: *Members Only*

Legal Name

Current Member

Data Collection Method

Program Collaborators

Contact Person/Title (If different frm Collaborators)

Address (Principal/Administrative Office)

Mailing Address (If different from above)

Phone

Fax

Website

Project Name

Purpose

Amount Requested (Up to $1,000)

Total Project Cost

Project Goals

Project Beginning Date

Project Ending Date

Geographic Area to be Served

I CERTIFY, TO THE BEST OF MY KNOWLEDGE, THAT:

The tax-exempt status of this organization is still in effect,
This organization does not support or engage in any terrorist activity, and
If a grant is awarded to this organization, the proceeds of that grant will not be distributed to or used to benefit any organization or individual supporting or engaged in terrorism, or used for any other unlawful purpose.
Agree to the collection of pre and post-survey data as required

I agree with the above statement

Signatures:

Executive Director / Date (By typing my name below, I agree to the terms and conditions outlined in this document.)

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