Grant Application Date

MM

DD

YYYY

Our Organization has a 501(c)3 Status in Good Standing

YES

NO

NWI Funds Usage Only

Does your intended use of funds granted include support for Northwest Indiana only?

YES

NO

Organization Address

Please include Country or form will not submit properly

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Requestors Name *

First Name

Last Name

Requestors Phone

(###)

###

####

Organization Type

Cultural

Educational

Medical/Health

Social Service