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Serving The Community - Local Grants 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: ____________________________________________________________






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:  ____________


Signature:___________________________________ Date of notification: ________________

Date posted on website:________________________ Date filed: _______________________