Application for Assistance
The Executive Lions of Vallejo desire to make funds available to non-profits that meet our priorities. Our priorities include:
• Eye care /vision
• Elderly and the youth
• Educational, recreational, and therapeutic activities
• Vallejo residents
If you desire to apply for financial assistance please provide the information below:
Name of Contact and Contact Information:
Name of Organization
Your answer
Federal Tax ID
Your answer
CA Franchise Tax Entity #
Your answer
Contact Person & Position
Your answer
Address
Your answer
Phone Number(s)
Your answer
Email Address
Your answer
Amount Requested
Your answer
MISSION STATEMENT:
Provide the Mission of your organization.
Mission:
Your answer
DESCRIPTION OF PROJECT / ACTIVITY
Provide a description of the project / activity for which you are requesting funds. Indicate clearly which of the above priorities (eye and vision care, elderly, youth, recreation, education, therapeutic) this project meets. Indicate when and where the activity will take place.
Project Description:
Your answer
BENEFICIARIES:
Describe who will benefit and how many persons will be served.
Beneficiaries:
Your answer
AUTHORIZATION & SIGNATURE
I hereby declare that 1) I am authorized to act on behalf of the agency submitting this request, 2) my organization hereby indemnifies and holds harmless the Executive Lions for any action regarding this application and the project / activity for which the organization is requesting funds.
Name
Your answer
Title
Your answer
Date
Your answer
Submit
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