SPUMC Grant Application
Applicant First Name *
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Applicant Last Name *
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Applicant Title
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Applicant Phone Number *
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Applicant Email Address *
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Name of Organization
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Address of Organization *
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City *
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State *
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Zip Code *
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Website of Organization
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Contact Name (if different than above)
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Purpose or Mission of Organization *
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Non-Profit Identifier (ie 501(c)3)
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This request will fund (click on appropriate answer)
Amount Requested *
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Description of proposed project/program or equipment (for projects/programs-objectives, who will benefit from the program, when and how long the program will continue, expected outcome, overall budget; for equipment - objectives, who will benefit, will amount requested cover cost): *
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Are there any other sources of funding for this project/program or equipment? If so, please describe the other sources:
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If grant is awarded, to whom should the check be made payable: *
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By signing this application, you have indicated that you have answered all questions truthfully to the best of your ability.
Electronic Signature *
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Date: *
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