NHDSA - Organizational Grant Form

Name of Organization*

Street Address*

Contact Name and Position*

Contact Phone Number*

Reason for request (Be specific as to dollar request, program that is to be funded, program budget, people/community to be served)*

Is funding needed by a specific time? Explain:

Please provide the history and mission of your organization, how funds were spent in the past years if you received a grant from us, and include your annual budget or report:*