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Operation

Round Up

Organization Information

Legal Name of Organization
Address:
Telephone: Fax:
Name/Title/E-Mail of Person submitting application:
Direct Phone # Cell Phone #
Is your organization an IRS 501(c) not-for-profit?    yes    no

List number and classification of those served in the following counties during the previous fiscal year:

County # Served Classification (individual/family/group)
Carroll
Haralson
Heard
Paulding
Polk
Troup
Does agency serve outside the counties listed above?    yes    no

If yes, please provide the following:

County Number served Classification (individual/family/group)
Has your organization ever submitted a grant to Carroll Electric Membership Foundation?    yes    no
If yes, date of last grant request submitted:
Has your organization ever received any funding from our Foundation?  yes    no
If yes, date(s) and amount(s) received:

Request

Project/Program Name:

Amount of Request:

If partial funding is awarded, will you be able to complete this project/program?

List individually other funding sources for this project/program. Include amounts and whether received, committed, or projected/pending:

Source #1 Amount Status
Source #2 Amount Status
Source #3 Amount Status

The following MUST accompany this application: (Must be typed)

  • Organization's Mission Statement or Statement of Purpose
  • Project Description (Specific - 1 page maximum)
  • Project Goals and Objectives (Specific - 1 page maximum)
  • Explanation of how the funds will be used (cost estimates for equipment or contract work)
  • IRS 501(c) documentation - if applicable
  • List of Board of Directors (include addresses and phone numbers)
  • Latest Annual Report if available
  • Audited financial statements (last 2)
  • Budget & cash flow statements for the current year
  • List of current funding sources
  • Three letters of recommendation from Business Associates (must be familiar with but not affiliated with the organization) These letters must be typed and signed - 1 page maximum
  • 11 copies of the application and supporting documents

If grant is awarded:

  • A Final Report Form will be submitted within 6 months of receiving the grant. Failure to submit the report will disqualify your organization from future funding.
  • Follow-up site visits to observe completed projects or ongoing programs may be conducted by the Carroll EMC Foundation staff and/or its Board Members.
  • The applicant and the organization hereby authorize the Carroll EMC Foundation and Carroll EMC to use their name(s), photographs, and any other information about the grant in various types of publicity.

Must be completed:

Are you a member of the immediate family of any director of Carroll EMC Membership Foundation, or of any employee or director of Carroll EMC?

Person submitting application?  yes    no
Representative of organization signing application?  yes    no
Board Officer of organization signing application?  yes    no

The information contained in this statement is for the purpose of obtaining funding from the Carroll Electric Membership Foundation, Inc. on behalf of the undersigned. Each undersigned understands that the information provided herein is used to consider the request for funding, and each undersigned represents and warrants that the information provided is true and complete and that the Carroll Electric Membership Foundation, Inc. may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Carroll Electric Membership Foundation, Inc. is authorized to make all inquiries they deem necessay to verify the accuracy of the statements made herein.

 

 
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