Children's Medical Ministries Request for Funding

Children's Medical Ministries Request for Funding

International Ministries benefiting Children
Name of Organization:
Website address:
Countries Served:
Charitable Purpose of Organization:
Number of People Served:
Amount Requested:
Proposed Usage of Funds Requested:
Name of Representative:

First Name Last Name
Title:
Email:
example@example.com
Address of Organization:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number of Organization:
Please enter a valid phone number.
Is the organization a 501(c)(3) nonprofit?(if so, email a copy of your IRS Determination Letter to childmedhis@gmail.com)

Yes No
Board Members of the Organization:
Provide 2 references for the Organization:
Reference #1
First Name   Last Name
Email
Area Code   Phone Number
Relationship:
Reference #2
First Name   Last Name
Email
Area Code   Phone Number
Relationship:
By signing below, I certify that (1) the grant funds will be used properly and in accordance with this application, (2) the grant funds will be used within six moths of receipt and (3) validation of the usage of funds, including pictures will be submitted to Children's Medical Ministries upon completion of the project.
Signature

Clear
Date

Month Day Year
Date
Should be Empty: