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Contact Information
Date of Application:_________________________ Tax ID:__________________________

Legal Name of Applying Organization:__________________________________________________________

(Should be same as on IRS determination letter and as supplied on IRS Form 990) Is your organization a 501(c)3 ? ____Y

Year Founded:_____________

Address:__________________________________________________________________________________

City:_______________________________ State:______________________ Zip Code:________________

Organization Website:_______________________________________________________________________

Executive Director:_________________________________________________________________________

Title:___________________________________

Phone Number:__________________________ Email:_______________________________________

Contact Person (if different):_________________________________________________________________

Title:___________________________________

Phone Number:__________________________ Email:_______________________________________

Board of Directors and Titles:

____________________________________________ _______________________________________

____________________________________________ _______________________________________

____________________________________________ _______________________________________

____________________________________________ _______________________________________

____________________________________________ _______________________________________

____________________________________________ _______________________________________

____________________________________________ _______________________________________

Board Chair:_______________________________________________________________________________

Phone Number:__________________________ Email:_______________________________________

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