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Grant Request Application Form

Applicants Name:
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Date:
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Organizations Mission/Purpose:
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Submitted By:
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Title:
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Mailing Address:
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Zipcode
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City
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E-mail Address:
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Phone:
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Are You A 501c (3) Designated Organization?
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Tax ID Number:
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Website Address:
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The authorized representatives of this organization listed below request a grant in the amount of:
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For the purpose of: (Please attach vendor invoices, sales slips, quotations or other data to show you meet the criteria and requirements for this grant.)
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The Breaking Barriers Foundation Mission Statement is “Meeting Needs, Pursuing Dreams, Achieving Goals, and Improving Quality of Life”. Please elaborate on how the grant, if approved, will accomplish that goal and what percentage of total funds needed will be provided by this request:
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What other funding sources have you considered and, if so, were those approved?
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Additional information to support the grant request:
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