Local Grants Program - Grant Application Form

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Middletown Rotary Club Grant Application

P. O. Box 1107 Middletown, CT 06457

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Agency/Group: ________________________________________________________________

Program or Project: ____________________________________________________________

Contact:_____________________________________________________________________

Address:_____________________________________________________________________

City: _______________________ State: ____ Zip: _________ Telephone: ________________

Contact Email: ____________________________ Website: ___________________________

Rotary Priority Addressed:  ______________________________________________________

Amount requested: $______________ Date Grant is needed by: ________________________

Purpose and population to be served:

Proposed outcome/benefit:

How the Middletown Rotary Club will be acknowledged/recognized:

Total Project Budget: _____________________

Other funding sources for this project:

Committee Review   Date:______________           Board Review  Date: ________________

Action:  Approved: ________Denied   ________      Amount Recommended:  ____________

Reason:_____________________________________________________________________

Signature:___________________________________ Date of notification: ________________

Date posted on website:________________________ Date filed: _______________________