Grant Specific Intake Form

Grant Specific Intake Form
Owner's Name

First NameLast Name
Owner's Personal Email Address
example@example.com
Owner's Personal Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Point of Contact (if different from the Owner)

First NameLast Name
Title/Position
Authorized Point of Contact's Email Address
example@example.com
Authorized Point of Contact's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Which best describes your business?
Choose only one (1)
Date business started

MonthDayYear
Date
Business/Organization Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business/Organization Type
Select one and provide the applicable supporting document
If Other Please Elaborate
Legal Business Structure
Select one
If Other Please Elaborate
Target Population (You may choose more than one)
If Other Please Elaborate
What is the mission of your business or organization?
What does your business or organization do?
Who do you serve?
Target Population (You may choose more than one)
If Other Please Elaborate
What geographic area do you serve or intend to serve?
Do you plan to expand into additional geographic areas?
What problem or need are you addressing?
What impact or outcomes do you hope to achieve?
Minority Certifications (select all that apply)
Are you a faith-based organization/house of worship? If yes
Website
www.name.com
Facebook URL
Instagram URL
X URL
EIN/Tax ID
Number of Employees
Annual Revenue Range
Current Annual Operation Budget
Current Cash on Hand
Existing Business Debt
Funding Preferences. If grant funding is unavailable or your application is not approved, would you like us to explore other funding options on your behalf? (Select all that apply.)
If applying for loans, what is the maximum loan payment you would be comfortable with?
Funding Need/Amount requested
Funding Purpose

(Select all that apply)
Business Operations
Program and Mission Support
If Other Please Elaborate
Project Name/Title
Project Summary
Brief Description of How Funds Will Be Used
Prior Funding History
Yes/No - If yes, which programs?
Past Grants Applied For/Won
Existing Partnerships (if any)
Supporting Documents (please select and provide any of the following documents that are available. If the document is not applicable to your organization or is unavailable, you may leave it unchecked.)
If Other Please Elaborate
Please upload the supporting documents you've checked

IRS Letter, Budgets, Financials, Annual Report, Logo, etc.
Cancelof
How Did You Hear About Us
Signature
Today's Date

MonthDayYear
Date
Please verify that you are human
Should be Empty:

Grant Specific Intake Form

Funding Purpose