2008 Chamber Foundation Grant Application

Polk County Chamber Foundation, Inc.

2753 Lynn Road, Suite A, Tryon N.C. 28782

PH 828-859-6236    Fax  828-859-2301

GRANT APPLICATION 2008  -  DUE DATE Monday March 3, 2008

1. Name of Organization:____________________________________________________________

2. Contact Name and Title:___________________________________________________________

3. Phone Number:______________________________ Fax Number:__________________________

4. Address/Mailing    ________________________________________________________________

    Address/Business   ________________________________________________________________

    City State Zip         ________________________________________________________________

5. E-mail Address:_________________________________________________________________

                                (Is this address for specific personnel or organizational? -Please circle one)

6. How long has this organization been in existence? ________________________

7. Tax Status (check one)

     ___ Tax exempt organization [ 501(c)(3)]                               ___  Governmental tax-exempt unit

    ___ Other non-profit (specify status)_____________               ___ Incorporated association

   ___ Affiliated with tax-exempt organization                              ___ Religious congregation      

    (specify) _________________________

                                                                                                        ___ Other (specify  

Please attach a copy of your organization’s IRS tax status determination letter (not applicable to government agencies or religious congregations). A tax exempt number is not sufficient.

8. PROJECT DESCRIPTION:________________________________________________________

Time period your project covers: __________________to__________________

                                                                      Month/Year                          Month/Year

9.  Amount requested from the Polk County Chamber Foundation:                    $________________

10. Total estimated cost of your project: $____________________

11. Other sources of funds for this project only:

 12.  Signatures of the Governance Authority Chairperson and CEO/Executive Director

____________________________      _________________________________      __________________

 Governance Authority Chairperson                   CEO/Executive Director                                 Date