Community Outreach Grants Application

Organizational Profile

Organization Name*

Address*

Street Address Address Line 2 City State ZIP Code

Website*

Organization Phone Number*

DBA/Alternate Name of Organization

EIN*

Please provide your organization’s purpose or Mission Statement.*

Is the Organization Tax Exempt?*

Yes

No

Your organization is not eligible for West Cancer Foundation funding. Please consider reapplying if your status changes. Return to our home page.

Primary Contact

Name*

First Last

Title*

Phone Number*

Mobile Phone*

Email Address*

Secondary Contact

Name

First Last

Title

Phone Number

Mobile Phone

Email Address

What is the primary focus of your organization?*

Please select based on your organization’s focus, not the focus of your event request. Please select from the below drop down.

What geographic area does your organization serve?*

Please check all that apply.

Shelby County

DeSoto County

Crittendon County

Event Details

Event Name*

Please describe your event, how it will align with West Cancer Foundation’s mission and how grant funds will be used.*

Event Start Date*

Event End Date*

Event Start Time*

:

Event End Time*

:

Event Location*

Street Address Address Line 2 City State ZIP Code

Number of attendees expected*

Please enter a number greater than or equal to 1.

Amount Requested*

Please enter a number from $500 to $5000.

Please enter a number from 500 to 5000.

Please provide any additional information that may assist us in considering your event for grant funding.*

Please explain how West Cancer Foundation’s support will be acknowledged with this grant?

Organization Documents

Annual Report

Max. file size: 50 MB.

501(c)(3) Letter of Determination*

Max. file size: 50 MB.

Certificate of Insurance*

Max. file size: 50 MB.

Please upload the organization’s current year W-9 form*

Max. file size: 50 MB.

Board Roster*

Max. file size: 50 MB.

Program/Project Budget*

Max. file size: 50 MB.

Organization Budget*

Max. file size: 50 MB.

Charitable Solicitation Certificate*

Max. file size: 50 MB.

Please upload any relevant sponsorship proposal documents.*

Drop files here or

Max. file size: 50 MB.

Organizational Profile

Primary Contact

Secondary Contact

Event Details

Organization Documents

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