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ELECTRIC COOPERATIVE
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Operation Round-Up Application
For Organizations and Agencies
Applicant Information
Name of Organization
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Email
*
Contact Person
*
Title
*
Organization Information
Is your organization requesting funding exempt from payment of income tax?
*
Yes
No
Please upload a copy of your most recent financial statement(s) and a copy of your 501c3 if applicable.
If you do not have a copy of a financial statement or 501c3 form, please explain why.
Approximate number of individuals, families, or groups served in the last year.
*
Funding
Purpose of funds
*
Amount requested (not to exceed $10,000)
*
Please provide an estimate or invoice for your request.
Please explain how the funds will be used.
*
List other sources of funding, what the status is of the request (received, pending, applied, etc.) and the amount.
*
How are your organization's programs measured for effectiveness?
*
Has your organization received funding from Operation Round-Up in the past?
*
Yes
No
If yes, please explain.
References
Name
*
First
Last
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Name
*
First
Last
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Name
*
First
Last
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Read & Electronically Sign
*
The information contained in this statement is for the purpose of obtaining funding from the Adams-Columbia Electric Cooperative Trust on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding whether to grant funding, and the undersigned represents and warrants that the information provided is true and complete and that the Adams-Columbia Electric Cooperative Trust may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Adams-Columbia Electric Cooperative Trust is authorized to make all inquiries they deem to verify the accuracy of the statements made herein.
I agree
Name of Organization
*
Representative's Name
*