Foundation Funding Application
Is your organization a government unit or a public charity that is non-profit and tax-exempt under 501 (c)(3) of the IRS Code?
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Yes
No
If applicable, please attach a copy of your IRS exempt determination letter.
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Have you ever received funding from the QMG Foundation?
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Yes
No
If you answered yes to the above question, for what program or project?
Name of your organization/program
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Address of your organization
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of the head of your organization/program (please include title - CEO, Director, etc.)
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Email for the head of your organization
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example@example.com
Phone Number for the head of your organization
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Please enter a valid phone number.
Your Name (person completing the application)
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First Name
Last Name
How are you affiliated with the organization?
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(Volunteer, staff, board member, etc.)
Your Email
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example@example.com
Your Phone Number
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Please enter a valid phone number.
Brief overview of your mission and organization/program
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Which one of the Foundation focus areas are you applying for funding?
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Community Development
Health Initiatives
Youth Programs and Partnerships
Dollar amount of funds being requested
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Intended use of funds
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Please attach a project budget (if this is not applicable, please upload an explanation of why it is not).
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Please attach copies of bids, invoices or price quotes (if this is not applicable, please upload an explanation of why it is not).
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Please attach a list of your board of directors, including contact information (if this is not applicable, please upload an explanation of why it is not).
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What is the proposed time frame for using this funding?
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How many people will benefit from the project and what age group is being targeted?
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What geographic location will this project or program impact?
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Is this a pilot program? If not, please explain how it was previously funded.
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How do you plan to maintain this project/program following initial QMG Foundation funding?
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How would only partial funding from the Foundation impact your ability to provide this project, program, or meet general support needs?
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How will your organization contribute to this project?
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Is there a possibility of alternative funding for this specific request? If so, from what sources and in what amounts?
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Do you agree to file a QMG Healthcare Foundation funding report setting forth the expenditure of the funding money, when it was expended, to who it was paid, and the benefits received from the funds?
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Yes
No
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The head of the organization has reviewed and approved the submission of this grant.
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I certify that I completed this form, and the information I provided is complete and accurate.
Signature
Submit
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