Grant ApplicationPrintable Application Organization(Required)Contact Person(Required) First Last TitleAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneFaxEmail(Required) President/Executive Director(Required) First Last Board Chair Person(Required) First Last PhoneFaxEmail(Required) Program/Project Name (if applicable)(Required)Purpose of Grant(Required)Grant Start Period(Required) MM slash DD slash YYYY Grant End Period(Required) MM slash DD slash YYYY Amount Requested $(Required)Federal ID Number(Required)Project Budget(Required)Organization's Total Operating Budget(Required)Is there pending litigation or filed legal liens against your organization that would affect this grant? If so, please explain:(Required)Please indicate the main issue area(s) this project would address:(Required) Access to health care by the uninsured and underinsured Behavioral health needs, particularly those of children and families Prenatal health care Services to children at risk Populations with special needs Wellness and prevention of illness and injury Healthcare career opportunities Other If other, please elaborate:Locations(s) served:(Required) Crawford County, AR Franklin County, AR Logan County, AR Scott County, AR Sebastian County, AR LeFlore County, AR Sequoyah County, AR NameThis field is for validation purposes and should be left unchanged.
