Zoo, Arts & Parks Tier II
Requests LESS than or Equal to $15,000
2015 Application/2013 Evaluation
The entire application (including the signature pg. but excluding attachments) may not exceed 7 pages. It is highly encouraged that all applicants refer to the Application Guide. Do not use type smaller than 12 point font.
Name of organization: ______
Organization must be a 501(c)(3) or municipality. If your name is different from how it appears on your federal 501(c)(3) letter, an explanation is required.
1 / What is your organization’s eligible discipline?
2 / Are you a first time applicant? (YES or NO)
3 / How many people make up your organization? / Staff (paid)
Volunteers (unpaid)
Independent Contactors (paid)
4 / How many performances, events, and/or educational programs do you provide/hold in Salt Lake County (annually)?
5 / How many people attend your organization, events, &/or educational programs held in Salt Lake County (annually)?
6 / Of the number of people listed in #5 above how many were provided FREE admission at an event location within Salt Lake County?
7 / What is the number of artists, scholars, botanists, historians, etc. involved with your organization?
8 / Did you attend the ZAP application workshop? (YES or NO)
ZAP Tier II Application 2013
Page 1 of 6
2015 Request Amount: $______(Must be under or equal to $15,000)
Request Narrative (type in your responses under each question)
1. What is your organization’s mission statement? Please be brief.
2. What area(s) listed below, best describe what you're trying to achieve? Check all that apply.
Educational / Lifelong Learning / Creative EngagementFacilitator / Health & Wellness / Other (describe):
Performing / Social interaction through cultural means
Presenting / Fostering ethnic enrichment & awareness
3. What value does the community receive from your activities? Explain how your organization contributes to a vibrant/energetic cultural community in Salt Lake County? Your answer to this question should give a compelling argument as to why the ZAP Program should fund your project or operations.
4. Describe how your organization will specifically use the ZAP funding that you are requesting in this application.
5. Describe how your organization collaborates and partners with other organizations to advance your mission and serve the public.
6. What demographic BEST describes your audience? Check all that apply.
General audience (all ages, all demographics) / Local community / Other (Describe):Students (school age, university, & educators) / Avant-garde/Underground
Institutional residents: those in an assisted living situation, incarcerated, homeless, other / Older adults
Scheduled 2015/2016 Events
*If you are a museum or gallery & do not have special events but are open regularly, simply list your hours of operation.
Date(s) Scheduled / Venue or location / Event/description
(month/day/year) / (name or street address, city) / (name or type and full description)
2013 Evaluation Narrative** Answer these questions by referring specifically back to narrative in your 2013 ZAP application
E1. Describe what was accomplished using your 2013 ZAP funding (in Salt Lake County only). Be as specific as space allows.
E2. What sources of funding did your organization secure during this funding period? Please be specific and name actual sources. If your organization was able to leverage additional funding because of your ZAP award please explain how this was achieved.
E3. In the interest of transparency, were there any monetary conflicts of interest that your organization has engaged in during this period? This means the sale or purchase of services or goods by the organization from staff, board or relatives of staff or board. If none, state none. If yes, please explain the transaction thoroughly.
Actual organizational activities provided during the 2013 grant period (as indicated in 2013 application)2013 Actual / Venue or location / Event/description
(Month/Day/Year) / (name or street address, city) / (name or type and full description)
Additional Information / YES / NO
Are you a member of the Utah Nonprofits Association?
If you are not a member of UNA, does your organization abide by all nonprofit ethics and professional standards?
If you are a part of a public university, college, or educational affiliate, does your program receive more than 50% of its funding from state funds?
Choose one by marking with an X / 501(c)(3) / Municipality / Affiliate or part of a University
Date organization/agency was founded
Age of Organization
Date of 501(c)(3) Status
For what 12 month time period are you asking for funding (may use a 12 month timeframe between January 2015 and December 2016)?
Utah Business Registration: Entity # [for 501(c)(3)’s only]
2015 Tier II Application (Requests > $15,000)/2013 Evaluation Page 2
If you need to include any addition explanations – include them here:
Organization Address:
City, State, Zip Code:
□ Please check box if this is a new address
Mailing Address (if different from above):
City, State, Zip Code:
□ Please check box if this is a new address
Main Org Phone:
Fax:
Website:
Application Submitted By:
Name:
Title:
Phone:
Email:
Alternate Contact Person (must include):
Name:
Title:
Phone:
Email:
Please list the individuals with their titles that have the authority to sign contracts for this organization, and that are most likely to sign a contract with Salt Lake County if funded:
How are these people authorized to bind the organization (with their signature)? In other words how did they receive the authority to sign for the organization. For example, through bylaws, from the board, etc.
ZAP Tier II 2015 Application (Requests ≤ $15,000)/2013 Evaluation Page 6
ZAP Tier II 2015 Application (Requests ≤ $15,000)/2013 Evaluation Page 6
Signature
The undersigned hereby acknowledges that the submitted information is true and correct and that she/he has the authority to bind the applying organization. The undersigned also affirms that the Governing Board of the organization is aware of and approves of the contents of this application. The undersigned also acknowledges that the information provided and the images you submit may be used to highlight your organization on the Zoo, Arts and Parks website and other ZAP publications.
Signature
______
Print name of authorized signature Print title Date
Check you have included: Proper # Application Copies & all additionally required documentation
Document Type / # of Required Copies / CheckZAP 2015 Application/2013 Evaluation / One single sided original PLUS 6 copies
Local Arts Agencies (only): One Single sided original PLUS 11 copies
Documentation promoting events on NowPlayingUtah (NPU) website – for those groups that received 2013 ZAP funding / 1 copy
Sample(s), showing how ZAP is acknowledged on your program, brochure, newsletter, website, etc. / 1 copy of each type
List of board members with contact information & skills/expertise they bring to your organization / 6 copies
Local Arts Agencies (only): 11 copies
501c(3) Letter or Letter from municipality if applying as city or township / 1 copy
ZAP Tier II 2015 Application (Requests ≤ $15,000)/2013 Evaluation Page 6