Grant Application

Date

NAME OF ENTITY

FEDERAL EIN

Is the entity a NON-PROFIT 501(c)(3)?

Yes

No

Is the name above the same as it appears on the IRS Letter of Determination?

Yes

No

If no, explain:

BUSINESS ADDRESS

City

State/Province

Zip/Postal

Country

Is the mailing address the same as the business address?

Yes

No

If no, what is the MAILING ADDRESS (street, city, zip code, & state)

Organizational Demographics

Of the individuals served, what percentage identify as:

American Indian or Alaska Native

%

Asian

%

Black or African American

%

Caucasian (Light-skinned; of European Origin)

%

Hispanic or Latino

%

Native Hawaiian or Other Pacific Islander

%

Prefer not to say / other

%

Of the individuals served, what percentage identify as:

Male

%

Female

%

Transgender

%

Gender non-conforming

%

Other

%

Prefer not to say

%

Of the individuals served, what percentage identify as:

Under 18

%

18 to 24 years old

25-34 years old

%

35-44 years old

%

45-54 years old

%

55-64 years old

%

Over 65 years old

%

Of the individuals served, what percentage identify their highest level of education as being:

Some high school, no diploma

%

High school diploma or GED

%

Some college, no degree

%

Associate (2 year) degree

%

Bachelor's (4 year) degree

%

Master's degree

%

Doctorate degree

%

Prefer not to say

%

Of the individuals served, what percentage reported the following as their primary substance used:

Alcohol

%

Cannabis

%

Opioids

%

Stimulants

%

Polysubstance Use

%

Other

GEOGRAPHIC AREA SERVED (Please utilize zip codes if possible)

Feel free to elaborate on demographic information below:

ORGANIZATION CONTACTS

CHIEF EXECUTIVE'S NAME & TITLE

EMAIL ADDRESS

CONTACT'S NAME & TITLE (if different)

TELEPHONE NUMBER

TYPE OF BUSINESS OR ENTITY

WEBSITE URL

ORGANIZATIONAL DEMOGRAPHICS : Please provide as much demographic information as you can. This may include information about race/ethnicity, age, disability/accessibility needs, education, etc.

GEOGRAPHIC AREA SERVED

List any CERTIFICATION/ACCREDIDATIONS obtained by the organization

Grant Application

Grant Application

Organizational Demographics

Of the individuals served, what percentage identify as:

Of the individuals served, what percentage identify as:

Of the individuals served, what percentage identify as:

Of the individuals served, what percentage identify their highest level of education as being:

Of the individuals served, what percentage reported the following as their primary substance used:

ORGANIZATION CONTACTS

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