Nolin Operation Round-Up® Application for Donation for Organization/Agency

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Nolin Operation Round-Up ® Inc. 411 Ring Road Elizabethtown, Kentucky 42701

Email *

DEADLINE FOR APPLICATION IS 5:00PM EDT MAY 1, 2023

Name of organization *

Address (street/P.O. box, city, state and zip code) *

Phone number *

Contact person *

Is organization requesting funding exempt from payment of income tax? If yes, copy of letter (Form 501[c]3) from the Internal Revenue Service must be emailed to mrogers@nolinrecc.com *

Yes

A copy of financial statement(s) for most previous year must be provided by email to mrogers@nolinrecc.com *

Statement sent

Number of individuals, families, or groups served in Hardin County last year *

Number of individuals, families, or groups served in LaRue County last year *

Does agency serve outside Hardin or LaRue Counties? If yes, please provide information on number served and location *

State Purpose of Organization/Agency request (Include amount requested and specifics of how funds will be used) *

List other sources of funding for use of request as described in the above *

How are agency's programs measured for effectiveness *

List three (3) references below

Reference 1 (name, contact phone number and mailing address) *

Reference 2 (name, contact phone number and mailing address) *

Reference 3 (name, contact phone number and mailing address) *

The information contained in this statement is for the purpose of obtaining funding from Nolin Operation Round-Up on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding to grant funding, and each undersigned represents and warrants that the information provided is true and complete and that the Nolin Operation Round-Up may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Nolin Operation Round-Up is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.

To verify that you agree with the above statement, please provide the name of the organization, the name of the person filling out this form and the date. *

DEADLINE FOR APPLICATION IS 5:00PM EDT MAY 1, 2023

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms