Grant Application

Cover Sheet

Grant Project Req'd

Organization Type Req'd

EIN # Organization Name

How did you hear about us

Brief Description of what the grant money would be used for Req'd

Amount Requested From CHC Req'd

Your Matching Funds Req'd

Total (Request + Match) Req'd

Project Location Req'd

County Req'd

Application Organization (name of organization) Req'd

Mailing Address Req'd

City Req'd

State Req'd

Zip Code Req'd

(all formal correspondence will be mailed to this organization contact at this address)

501(c)(3) Tax Exempt Holder (verification must be attached)

Project Contact Req'd

Daytime Phone Req'd

Evening Phone Req'd

Email Address Req'd

Additional contacts who may be contacted regarding this project (different from above).

Contact

Daytime Phone

Evening Phone

Grant Writer

Daytime Phone

Evening Phone

Grant Application:

Grant Application: Req'd