Organizational Information
Organization Name

Address

Website URL

Employer Identification Number (EIN)

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

Staff Members
Paid Full TimePaid Part TimeVolunteer
Affiliated with National/Regional Organization?
YesNo
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
Name:
Tite/Position:
Phone Number:
Email:
Mailing Address: