GRANT DEADLINE MAY 31.
Non-Profit Organization: ____________________________ Date: _____
Requester Name: ____________________________________________
City: __________________________ State: ________ Zip: _________
Phone: ________________________ Email: ______________________
Project Name: ______________________________________________
Dollar Amount
Requested: $ _______________ EIN#_______________
Reason for funds: ____________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________________
Non-Profit Organization Authorized Signature:
Print Name: _______________________________________________________
Title: ____________________________________________________________
Signature of Printed Name:
___________________________________________
Earthly Angels Autism Fund Authorized Signature:
Dollar Amount Approved: $ _______________
Printed Name: _____________________________________________________
Signature of Printed Name: ___________________________________________
Email to: rdeliseo@comcast.net or mail to: EAAF, 32 Huckleberry Lane, Duryea, PA 18642