Grant Application Online Form

Use this form to apply for a CCHF grant.

Applicant Name: *

Who will be the primary contact person?

Organization: *

Street Address: *

City: *

State: *

Zip Code: *

Phone Daytime:

Phone Evening:

Alternate Contact Person:

If different from Applicant

Contact Email: *

Contact Phone:

Tax Exempt Status: *

Per Section 501C of the IRS Code: (Proof must be mailed to CCHF, PO Box 504, Canton, CT 06019)

Tax Exempt ID Number: *

Grant Objective: *

Grant Duration: *

Duration of the program

Population Targeted: *

Grant Amount Requested: *

Please itemize the specific amount being requested

Total or Partial Funding: *

Is the amount being requested for total or partial funding?

Other Funding Sources: *

Are other groups being asked for funds?

Comments:

Please provide any additional documentation that will help us to evaluate your proposal.

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