Date of application:
Organization 501(c)(3) name:
Address of organization:
City, State, Zip
Telephone:
Fax:
Internet Address:
Executive Director:
Contact person and title (if not Executive Director):
Is your organization an IRS 501(c)(3) not-for-profit? Yes No If no, you are not eligible for funding by NYNEX.
Are you an agency or partner funded by United Way? Yes No If yes, you are not eligible for funding by NYNEX.
Purpose of grant:
Grant request ($):
Period this grant will cover:
From:
To:
Total organizational budget (for current year) ($):
Total project budget ($):
Project name (if applicable):
For office use only:	Education Health and Human Services Arts and Culture Civic and Community