Online Form:

Phone

(###)

###

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Primary Contact Person (Name and Title) *

Name and Title

First Name

Last Name

Telephone

(###)

###

####

Cell

(###)

###

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Incorporated as Non-Profit?

Yes

No

Date Incorporated

MM

DD

YYYY

Tax Exempt Status

Has your organization qualified as a Tax-Exempt Entity under State Law and Section 501(c)(3) of the Internal Revenue Code?

Yes

No

These funds will be used to address *

Programs for the disadvantaged

Special concerns of the elderly

Youth Development

Adult Advancement

Artistic, Cultural & Historical Heritage Programs

Science, Health & Environmental Programs

Disaster Relief

Visalia and/or Surrounding Community

Project Dependency?

Without the VRCF Grant, does your project go forward anyway?

Yes

No

Funding Alternatives

Are there alternative sources of funds for the project?

Yes

No

Contact's Phone

(###)

###

####

Chair's Name

First Name

Last Name

Vice-Chair's Name

First Name

Last Name

Treasurer's Name

First Name

Last Name

Secretary's Name

First Name

Last Name

Do you utilize volunteers?

Yes

No

Outside Fund Raisers

Are outside fund raisers employed?

Yes

No

Are Accounts audited by:

A certified public account

An auditing committee of the Board

Other

Verification of Accuracy *

I certify that the aforementioned and enclosed information is complete and accurate. (To be signed by the Chair of the Board, or other Board Member). Your initials, plus the IP address and server date stamp on this form at the time of submission serves as your signature.)

Yes