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Healthcare Resources Foundation Grant Application Date: _______________ 1. Name of Applicant: _____________________________________________________________ Project Name: _________________________________________________________________ Address: ______________________________________________________________________ 2. Contact Person: _________________________ Title: ________________________________ Telephone No.: ______________________ Fax No.: ______________________________ 3. Grant Amount Requested: ________________________________________________________ Project Budget: ______________________ Project Timetable: ______________ To Begin: _____________ To End: ____________

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Page 1: Date: _______________ 1.Name of Applicant: _____________________________________________________________ Project Name: _________________________________________________________________

Healthcare Resources FoundationGrant Application

Date: _______________

1. Name of Applicant: _____________________________________________________________

Project Name: _________________________________________________________________

Address: ______________________________________________________________________

2. Contact Person: _________________________ Title: ________________________________

Telephone No.: ______________________ Fax No.: ______________________________

3. Grant Amount Requested: ________________________________________________________

Project Budget: ______________________

Project Timetable: ______________ To Begin: _____________ To End: ____________

Page 2: Date: _______________ 1.Name of Applicant: _____________________________________________________________ Project Name: _________________________________________________________________

Healthcare Resources FoundationGrant Application

(Page 2)

4. Specific Purpose of Project :

Goals/Objectives to be met :

Page 3: Date: _______________ 1.Name of Applicant: _____________________________________________________________ Project Name: _________________________________________________________________

Healthcare Resources FoundationGrant Application

(Page 3)

Methodology :

Justification of need :

Page 4: Date: _______________ 1.Name of Applicant: _____________________________________________________________ Project Name: _________________________________________________________________

Healthcare Resources FoundationGrant Application

(Page 4)

Special Characteristics of program/project (if applicable):

How will the project be continued when grant award expires?

Page 5: Date: _______________ 1.Name of Applicant: _____________________________________________________________ Project Name: _________________________________________________________________

Healthcare Resources FoundationGrant Application

(Page 5)

5. Please provide a brief description of your organization:

Organization’s primary purpose:

Page 6: Date: _______________ 1.Name of Applicant: _____________________________________________________________ Project Name: _________________________________________________________________

Healthcare Resources FoundationGrant Application

(Page 6)

Geographic service area:

Primary constituency served:

Page 7: Date: _______________ 1.Name of Applicant: _____________________________________________________________ Project Name: _________________________________________________________________

Service programs offered:

Please list contributors to your organization:

Healthcare Resources FoundationGrant Application

(Page 7)

Page 8: Date: _______________ 1.Name of Applicant: _____________________________________________________________ Project Name: _________________________________________________________________

Healthcare Resources FoundationGrant Application

(Page 8)

Please list income sources for the proposed project:

6. Please attach financial information for the organization - include operating budget for proposed year and audited financial statements for the previous two fiscal years.

7. Please attach financial information for the project - an operating budget for the year.

8. Please attach a list of the members of the officers of the organization and their business affiliations.

9. Please attach the name, title, credentials and outside affiliations of the person within the organization that will be responsible for the administration of the project and grant.

10. Please attach a copy of the organization’s 501 (c)(3) certificate, as determined by the IRS .

11. Please attach a copy of the organization’s mission statement as contained in the articles of incorporation or by-laws.

12. Please provide any additional information related to your organization, that you believe may assist us in evaluating your request. (Please limit attachments to 4 pages)

I declare that I have examined this Grant Application, and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct and complete.

________________________________ _____________________________

Signature of Officer Date

______________________________________ __________________________________

Name of Above Officer (type or print) Title of Officer (type or print


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