Grant Application

    Organizational Information
    Organization Name


    Website URL

    Employer Identification Number (EIN)

    Management Governance-Please provide a list of Board Members/Trustees and Officers

    Staff Members

    Affiliated with National/Regional Organization?

    If YES, please provide Name, Address and Web Site URL

    Organizational Purpose
    Organization Vision and Mission:

    Brief Explanation of Primary Services (Up to 4) and Service Area of your Organization:

    Population Profile – Brief description of those directly benefitting from your Organization:

    Project Information
    Provide a brief summary of Project for which this grant is requesting funds:

    Project Details: Bulletized explanations of the following:

    Why the project is needed:

    What the project entails:

    Profile of those that will benefit:

    Project goals:

    Total amount your organization is requesting from Roman Open Charities:

    Impact if not fully funded/partially funded:

    Alternative Funding:

    Contact Information
    Phone Number:
    Mailing Address: