CCBNA Grant | Capitol City BNA

Legal Name:

Current Member:

Data Collection Method:

Program Collaborators:

Email:

Contact Person/Title (If different frm Collaborators):

Address (Principal/Administrative Office):

Mailing Address (If different from above):

Phone

Fax:

Website:

Project Name:

Purpose:

Amount Requested (Up to $1,000):

Total Project Cost:

Project Goals:

Project Beginning Date:

Project Ending Date:

Geographic Area to be Served:

The tax-exempt status of this organization is still in effect,
This organization does not support or engage in any terrorist activity, and
If a grant is awarded to this organization, the proceeds of that grant will not be distributed to or used to benefit any organization or individual supporting or engaged in terrorism, or used for any other unlawful purpose.
Agree to the collection of pre and post-survey data as required

I agree with the above statement

Executive Director / Date

Thank you for submitting!