2019-2020 MoCA Westport Space Grant Partnership Program
Email address *
Name of Organization *
Your answer
Contact Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Organization Mission Statement *
Your answer
What impact does your organization have on the community at large? *
Your answer
Proposal for use of space *
Please include dates, times, number of attendees, facility needs and purpose of event
Your answer
Is your organization a qualified and verifiable 501(c)(3) organization? *
Required
Is your organization based in Fairfield County? *
Required
Can your organization provide a certificate of insurance for event? *
Required
Does your organization uphold high ethical standards without regard to race, color, religion, sex, sexual orientation, age, national origin or disability? *
Required
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Westport Arts Center.