EmpowerED Media Scholarship Program Application
Company Name
*
Contact Person
*
First Name
Last Name
Type
*
Please Select
Small Business
Nonprofit
Community Entity
EIN
*
Email Address
*
example@example.com
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Brief description of the organization’s mission
*
Briefly describe your business and services
*
Explanation of how digital services support their mission
*
Preferred Contact Method
*
Email
Phone
Explanation of current financial constraints and why the scholarship is essential
*
Annual budget or revenue
*
Continue
Continue
Service Request
*
Website
SEO
Social Media
Description of community served (population, needs)
*
Recent Financial Documents
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
501(c)(3) documentation for nonprofits
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Consent and Acknowledgment
*
By signing this form you agree to the terms and conditions of the scholarship.
Terms and Conditions
Should be Empty: