Church/Ministry Incorporated Name

 Church/Ministry Incorporation State

Church/Ministry Incorporation Date

Church/Ministry Registered Street Address

Church/Ministry Registered City

Church/Ministry Registered State

Church/Ministry Registered Zip Code

Church/Ministry Main Area Code & Telephone Number

Church/Ministry Secondary Area Code & Telephone Number

Church/Ministry Corporation Contact Person

Church/Ministry Corporation Contact Person Position

Church/Ministry 501(c)3 Approval Date

Dollar Amount of Grant Application

Grant Proceeds To Be Used For

Remarks

My Name Is

My Email Address Is

My Area Code & Telephone Number Is

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