ORU ORGANIZATION APPLICATION FOR HOLIDAY ASSISTANCE

Organization/Agency Information

Name

Street or Mailing Address

City/Town

State

ZIP Code

Organization/Agency PRIMARY Contact

Primary Contact Person

Primary Contact Email

Please enter the Work, Home and/or Cell Phone Number for the Primary Contact Person

First Type of Phone Number for the Primary Contact Person

Enter Primary Phone Number

Do you have a Secondary Work, Home or Cell Phone Number

Please enter a Secondary Work, Home or Cell Phone Number

Secondary Type of Phone Number for the Primary Contact Person

Enter Secondary Phone Number

Organization/Agency ALTERNATE Contact

Alternate Contact Person

Alternate Contact Email

Please enter the Work, Home and/or Cell Phone Number for the Alternate Contact Person

First Type of Phone Number for the Alternate Contact Person

Enter Alternate's Phone Number

Does the Alternate Contact Person have a Secondary Work, Home or Cell Phone Number?

Please enter a Secondary Work, Home or Cell Phone Number

Secondary Phone Number Type for the Alternate Contact Person

Enter Secondary Phone Number

Tell Us About Your Services

Please describe the types of services that the organization provides to the community:

Number of families served in Defiance and Williams Counties per year

Number of families served outside Defiance and Williams Counties per year

Organization/Agency Financial Information

Please list other sources of funding for your services:

Has the organization requesting funds received a 501(c)3 exemption designation from the Internal Revenue Service?

Special instructions for the check if your organization is awarded a grant:

Please list the name of payee (if different than organization name), special notation required on the memo line, etc.

Legal Information

____________________________________________

Acceptance of contents of legal information

Signature of Authorized Representative