Harney County Cultural Coalition Grant Application Form
Project Name:
Applicant: ____________________________________________________________________________________
Contact Person: _____________________________________________________________________________________
Address: ___________________________________________________________________________________________
Phone: __________________________________ Email: ____________________________________________________
Amount Requested: _________________________________________
Project start date: Project completion date:
Does the Applicant have 501(c)(3) status? * _________yes __________no
If not, name of fiscal agent for project: _____________________________________________________________
Address: _____________________________________________________________________________________
Email:__________________________________________________________ Phone:________________________
Individual OR official of organization requesting grant funding:
_______________________________________________________________________________________________
Name (please print) Title
Signature Date
Fiscal Agent, if needed:
_______________________________________________________________________________________________
Name (please print) Title
____________________________________________________________________ _________________________
Signature Date
Applications must be postmarked by November 1, 2017. Late applications will not be accepted.
*Refers to an organization that has obtained tax-exempt status from the IRS under Section 501(c)(3) of the Internal Revenue Code.
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