Organization Name:  

Address:  

Address 2:  

City:  

State:   AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code:  

Email:  

Web Address:  

Phone:  

Fax:  

Federal ID/EIN#:  

Executive Director:  

Executive Director Phone:  

Contact Name/Title:  

Contact Name/Title Phone:  

Organization - Background Data

Please provide a one paragraph description of your organization, including a description of the community, group, and population your organization is trying to impact.

Please provide your mission statement.

Please provide a list of the organization's Board of Directors (include names, professional titles, and board positions).

Please list the top 5 committed funding sources for organization for current fiscal year.
Top 5 Funding Sources for Current Fiscal Year Amount Committed Type of Funder
1.
2.
3.
4.
5.

Please provide any comments (optional).