Mark Wahlberg Youth Foundation GRANT PRE-APPLICATION

Legal Name of Organization

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

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Name of Executive Director

First Name

Last Name

Primary Contact Name

First Name

Last Name

Primary Contact Title

Primary Contact Email

Primary Contact Phone

(###)

###

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Is your organization an IRS 501(c)(3) organization?

Yes

FED EID/EIN#

Please share your organization's mission:

Please provide the name of the program or project this grant will support:

If this is for general operating support please state that

Request Amount

Project/Program Description:

No more than four sentences, please

List the proposal's target population, constituents, and geographic communities:

Total number of Board members

Total number of full time staff:

Total number of part time staff:

Total annual operating budget for your organization:

Fiscal year end:

Project/program budget:

Period this grant will cover:

Have you received prior support from the Mark Wahlberg Youth Foundation?

Yes

If you answered yes, please provide calendar year(s) and grant amount(s):

Were you referred to us by a person or organization?

Yes

If you answered yes, please list your referral source: