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Rotary Works Impact Grant Application
Please complete this form in its entirety. Most fields are required. It is essential that you provide current and accurate information.
Eligible applicants must live in either Zone 33 or Zone 34 and be a member of a Rotary or Rotaract club for six or more months
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Name
*
Your answer
District
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Choose
6890
6900
6910
6920
6930
6940
6950
6960
6970
6980
6990
7000
7020
7030
7280
7305
7360
7545
7570
7600
7610
7620
7630
7670
7680
7690
7710
7720
7730
7750
7770
Club Name
*
Your answer
Preferred Phone Number
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Your answer
EMail
*
Your answer
Street Address
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Your answer
City
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Your answer
State
*
Your answer
Zip
*
Your answer
Country
*
Your answer
How long have you been a Rotarian or Rotaractor? (Please indicate which)
*
Your answer
Have you previously applied for a Rotary Works Impact Grant?
*
Yes
No
If so, did you receive assistance
Yes
No
Clear selection
When did you apply?
MM
/
DD
/
YYYY
The Impact Fund Review Committee will use this information to determine your eligibility, and may contact you for further information. Describe in detail (500 words or less) your career transition and the hardship it has placed on your financial circumstances
*
Your answer
CERTIFICATION STATEMENT -- By checking this box, I certify that the information contained in this application is true, correct and complete and that I am requesting assistance because of a financial hardship due to a career transition.
*
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May we use your story for future public relations and/or fundraising activities? Please note your name will not be used.
Yes
No
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