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Serving The Community - Local Grants Application Form
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Middletown Rotary Club Grant Application

P. O. Box 1107 Middletown, CT 06457

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Agency/Group: ________________________________________________________________

 

Program or Project: ____________________________________________________________

 

Contact:_____________________________________________________________________

 

Address:_____________________________________________________________________

 

City: _______________________ State: ____ Zip: _________ Telephone: ________________

 

Contact Email: ____________________________ Website: ___________________________

 

Rotary Priority Addressed:  ______________________________________________________

 

Amount requested: $______________ Date Grant is needed by: ________________________

 

Purpose and population to be served:

 

 

 

 

 

Proposed outcome/benefit:

 

 

 

 

 

How the Middletown Rotary Club will be acknowledged/recognized:

 

 

 

 

Total Project Budget: _____________________

 

Other funding sources for this project:

 

 

 

Committee Review   Date:______________           Board Review  Date: ________________

Action:  Approved: ________Denied   ________      Amount Recommended:  ____________

Reason:_____________________________________________________________________

Signature:___________________________________ Date of notification: ________________

Date posted on website:________________________ Date filed: _______________________