Organizational Information
Organization Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Website URL
*
Employer Identification Number (EIN)
*
Management Governance - Please Provide a list of Board Members/Trustees and Offices.
*
Staff Members
*
Paid Full-Time
Paid Part-Time
Volunteer
Affiliated with National/Regional Organization?
*
Yes
No
Please provide Name, Address and Website URL:
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Organizational Purpose
Organizational Vision and Mission:
*
Brief Explanation of Primary Services (Up to 4) and Service Area of your Organization:
*
Population Profile – Brief description of those directly benefitting from your Organization:
*
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Project Information
Provide a brief summary of Project for which this grant is requesting funds:
*
Project Details: Provide bulletized explanations of the following:
Why the project is needed?
*
What does the project entail?
*
Profile of those that will benefit:
*
Project goals:
*
Total amount your organization is requesting from Roman Open Charities:
*
Impact if not fully funded/partially funded:
*
Alternative Funding:
*
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Contact Information
Name
*
First Name
Last Name
Title/Position
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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