Funding Request Form Order Number What is the name and physical address of the agency/organization making the request? Agency / Organization Name: Contact Person Street Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Pleases write check to: Mailing address: What are your organizations goals and mission? How long has your agency / organization been in existence? What services does your agency / organization currently provide to our community? Is your agency / organization a non-profit organization? Are you a Pro Hunting Organization? Yes No How did you learn about SCI Flint and its funding opportunities? What is the name of the Project / Program that you are requesting funds for? Has SCI or the SCI Flint Chapter provided funding to your organization in the past? Yes No Please provide a detailed description of the project / program. Included in the description should be information about how many people the program will reach and how it will accomplish the goals and mission of SCI . Please provide (attach) a detailed budget sheet for the program for which you are requesting funding. The budget sheet should include the following items: a. Specific funding requested from SCI Flint Regional Chapter. b. Identification and amounts of any matching funds received or requested. c. Identification of the primary funding source for the project/program. d. Total project cost which should include a breakdown of any associated costs related to the project. Add File Have you requested funds from other sources if so please identify the funding sources and requested amounts? Should you only be granted a portion of the funds you are requesting from SCI Flint Chapter, will you be able to continue with the project / program? If no please explain. Briefly outline the project / timeline and when the requested funds would be needed. What is your organization doing to ensure the sustainability of this project / program in the future? How will SCI and SCI Flint Regional Chapter be recognized if your request is granted.