Contribution Application Form - New London

Name of Organization
Address
Street Address Address Line 2 City State ZIP Code
Is your organization a non-profit 501-C-3?
- Yes
- No
Tax ID #
What is your IRS classification?
Organization Chief Executive
Title First Last
Website
Organization Mission
Describe the nature of services provided by the non-profit organization.

Brief description of request
Target Audience
- New London
- Clintonville
- Manawa
- Hortonville
- Marion
- Weyauwega
- Shiocton
- Fremont
- Embarrass
Objectives of the program for which funds will be used
How will you determine whether your program/event accomplished its goal?
Approximate number of people served by this project/program for which support is being requested
What is the total budget for this project?
Total amount requested
Project start date
MM
DD
YYYY
End date for Endowment Fund-New London Support
MM
DD
YYYY
Date Response Needed By
MM
DD
YYYY
ThedaCare's mission is to improve the health of the communities we serve. Please briefly explain how your program/request supports this mission.
What other organizations are you approaching for funding and which have made commitments?
Are you aware of other organizations in your service area that address the need described in the grant request? If so, please identify them.

What are the long-term funding strategies for sustaining this effort (if applicable)?
Please list sources of revenue and amount.
Please list types of expenses and amount. Identify specific expense line items to which ThedaCare Foundation-New London grant dollars would be applied.

CAPTCHA
If you have supporting documentation please send it to the following: contributions@thedacare.org

AWARD PROCEDURE / REQUIREMENTS:
Letters of award or denial will be sent to each individual or organization making the request generally within 45 days of the grant submittal.

Contribution Application Form – New London