Date: ______

MILLARD ROTARY GRANT REQUEST FORM

Requested by: ______

1. Dollars Requested: $ ______.

2. Needed by What Date: ______.

3. Requested on Behalf of (Name of organization, Group or Individual):

______

4. Is the proposed recipient a tax exempt organization? Yes ______No ______

5. Is this a one time request, or will it require multiple years of funding? Please explain.

______

______

______

6. How is this request related to the goals of Millard Rotary?

______

______

______

7. What is the benefit to the community if this project is funded by Rotary?

______

______

______

8. What percentage of the funds will go toward administrative costs?

______

______

______

9. What recognition (if any) will our organization receive for participating in funding this request?

______

______

______

For Use by Millard Rotary Club Board of Directors Only
10. ____ The Board of Directors has approved this request, in part or in full, with the following comments:
______
______
______
11. ____ The Board of Directors has not approved this request.
______
______
______
12. ____ The Board will consider all or part of this request again at a future time.
______
______
______

Rev. 9/2005 2