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2018 Community Assistance Grant Request
Today's Date: *
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Requester's Name: *
Please provide your first and last name.
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Organization Name: *
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Organization Tax ID Number: *
If applicable
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Affiliation: *
How are you affiliated with the organization?
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Requester's Email Address: *
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Requester's Phone Number: *
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Amount Requested: *
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Check Made Payable To: *
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Address For Payment: *
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Intent For Norfolk Community League Funds: *
Describe how your organization intends to utilize the funds you are requesting from NCL.
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Benefit To Community: *
Describe how the community will benefit by your request. Please include the target audience.
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Other Contributing Organizations: *
Please indicate other organizations that have contributed to this endeavor, including those organizations that have been asked but declined to contribute. Include the name, contribution requested, and contribution received.
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Funds Date: *
When do you require the funds to be distributed?
MM
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DD
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YYYY
If NCL Is Unable To Fund: *
If NCL is unable to fund this request completely or at all, due to fund availability, what would happen to the above-mentioned proposal? Please indicate if a lesser amount would be acceptable.
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Contact For Questions: *
Please indicate whom in your organization NCL may contact with questions regarding this request, or to advise you as to the disposition of your request. Please indicate name, address, phone number, and email.
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Electronic Signature: *
By checking this box, I am providing my signature for this request.
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