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APPLICATION FORM

- MINISTRIES

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- ORGANIZATION INFORMATION
  
  Organization Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date Organization Established Please enter a date.
  
  501(c)(3) Non-Profit ID# Please enter valid data.
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Organization Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Fax Number Maximum 20 characters Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Executive Director Name Please enter valid data.
  
  Executive Director Phone Number Maximum 20 characters Please enter a phone number.
  
  Contact for This Request REQUIRED Please fill out this field. Please enter valid data.
  
  Contact Phone Number Maximum 20 characters Please enter a phone number.
  
  Organization Web Site Please enter valid data.
- Organization Profile
  
  Mission/Purpose/Objectives
  Summarize and/or attach relevant information
  
  Community Served
  (Approximate number of clients served annually)
  
  Current/Most Recent Year Please enter valid data.
  
  Prior Year Please enter valid data.
  
  Percentage of Client Base in Financial Need
  
  Basis of Financial Need Determination Please enter valid data.
  
  Geographic Area(s) Served
  Location of Clients Served
  Please enter valid data.
  
  Most Recent Annual Operating Budget
  Attach financial statement as appropriate
  Please enter valid data.
- Funding Request
  
  Amount Requested REQUIRED Please fill out this field. Please enter valid data.
  
  Needed by Date Please enter a date.
  
  Purpose and Benefit of This Grant If Approved REQUIRED
  Explain in detail and/or attach relevant information. Please list a specific need rather than just general operating budget.
  Please fill out this field.
  
  Impact to the requesting organization if this request is not/cannot be granted at this time: Please enter valid data.
  
  Does the Church of Christ the King currently or in the recent past provided other support to your organization ($s or other resources)? Yes No
  
  If YES, please explain the nature and amount/type of support provided by Christ the King
  
  Other comments/background information helpful to the advisory board in reviewing this request:
- Attachments Provided? Yes No
- To submit supporting documents, please email as an attachment to Jonathan Camiolo - jonathan@churchofchristtheking.org.
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