St. Joseph's

Community Health Foundation

308 2nd Ave SW

Minot, ND 58701

(701) 837-1726

Fax (701) 838-3517

GRANT APPLICATION

The mission of St. Joseph's Community Health Foundation is to promote and support projects and services that contribute to the mental physical and spiritual well-being of residents in Northwest - Northcentral North Dakota. The counties included are Bottineau, Burke, McHenry, McLean, Mountrail, Pierce, Renville, Rolette, Sheridan, Ward, and Wells.

This original form must be completed, signed, and returned in order to be considered for a grant. Questions should be answered fully on supplemental pages. Please submit the original application forms along with seven additional collated, stapled, duplexed proposal packets for committee review.

ORGANIZATION NAME:

______

ADDRESS:______

Street City State Zip

TELEPHONE: (____)______FAX NUMBER:(____)______

Organization Telephone Number Organization Fax Number

EMAIL ADDRESS: ______

CONTACT NAME: ______TITLE:______

HOME ADDRESS: ______

CONTACT'S HOME TELEPHONE: (____)______

Organization Tax ID Number: ______

PLEASE ANSWER QUESTIONS FULLY BY ATTACHING SUPPLEMENTAL PAGES IF NEEDED. PLEASE DO NOT REWORD QUESTIONS. ALL QUESTIONS MUST BE ANSWERED IN NUMERICAL ORDER.

1. What is the history and work of the applicant organization?

2. Month and year organization was started: ______

3. Project title: ______Pg. 1 of 2

4. Purpose of project (state in one concise paragraph):

5. Description of project: (Provide complete and detailed information.)

6. Amount of Request: $ ______representing _____% of total budget.

7. Specific date project or expenditure of funds will begin: ______

8. Specific date project will end or funds will be expended: ______

9. Specifically, how will the St. Joseph's Community Health Foundation's award be

expended?

10. Who will benefit from this grant (list communities, groups and/or individuals)?

11. Will this project reduce health care costs? If so, how?

12. How does this project meet the mission of St. Joseph's Community Health

Foundation?

13. How will your organization recognize St. Joseph's Community Health

Foundation's sponsorship of your project?

14. Is there a deadline after which grant funds would not be accepted? If yes, please

indicate date. ______

15. A. What other sources of funding will be applied for concerning this project?

B. If funding is received from other sources, how will these funds be used? (ie: If

your budget is $5,000.00 for this project and you receive a total of $10,000.00 from all

sources, what will you do with the additional funds?)

16. What plans are in place to fund the continued operation of your program?

17. If your organization is awarded a grant, you must evaluate its merit. How will you

examine the expenditures of the grant money in order to determine if the grant

has been beneficial to your program, has had no effect, or has brought changes to

your program?

  1. In the event of an award, St. Joseph’s Community Health Foundation would draft the grant check to:

______

______

SIGNATURE TITLE DATE

Submit the original application with all of the pieces identified on the “check list” plus 7double-sidedcopies of each item for a total of 8 packets.

Pg. 2 of 2