The Greek Orthodox Ladies Philoptochos Society s1

National Greek Orthodox Ladies Philoptochos Society, Inc.

Metropolis of Pittsburgh Greek Orthodox Ladies Philoptochos Society, Inc.

National Children’s Medical Fund

Grant Request Form

This document seeks to explore your program, its history, track record andneeds

The deadline for electronic submittal of your grant request is Friday, May 31, 2013.

Eligibility Requirements:

In order to be eligible for consideration, all applicant organizations MUST:

·  Have current 501(c)(3) status from the Internal Revenue Service.

·  Be located in or serve populations of the Metropolis of Pittsburgh, which includes the state of Pennsylvania with the exception of Philadelphia and the surrounding area, the state of Ohio including only Northeast Ohio as far west as Rocky River and Central Ohio as far south as Columbus, and the state of West Virginia.

·  Address as their mission or project intent one of the Priority Issues for funding.

·  Direct grants, scholarships or loans for the benefit of specific individuals.

Projects of organizations whose policies or practices discriminate on the basis of race, ethnic origin, sex, creed or sexual orientation.

Part I: Organization Information

Name of Organization: ______

Mailing Address: ______

City: ______

State: ______Zip/Postal Code: ______

Phone Number: (_____) - ______

Fax Number: (_____) - ______

Website: ______

Primary Contact: ______

Title: ______

Primary Contact Phone Number: (____) - ______

Primary Contact Fax Number: (____) - ______

Primary Contact Email: ______

Part II: Mission Statement (Statement of Purpose)

What is the mission of your organization? ______

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How would you describe your current constituencies? ______

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Which geographical locations do you serve? ______

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Who currently serves on your organization’s board?

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Provide a brief history of your organization. ______

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Part III: Pertinent Statistics:

Total annual budget in the last completed fiscal year? ______

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How many people did your organization serve last year? ______

Number of full-time employees does your organization employ? ______

Is your organization a 501(c)(3) public charity?

Yes ____ No ____

If so, please provide your organization’s Employer Identification Number (EIN)?

______

Did your organization have an external financial audit conducted in the last fiscal year?

Yes ____ No ___

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Grant Request Information

Project/Program Title:

______

Project Description: (Comprehensively describe the purpose of the project or program.

What issues or needs will the CMF grant help your organization address? ______

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What specific outcomes or deliverable do you plan to achieve with this project?

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How will the funds be used?

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How many children and families people do you estimate this project/program will serve? ______

How would you describe the specific constituency this grant is designed to affect?

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What is the total estimated budget/annual cost of this specific project or program?

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What other grants have you received for this project or initiative? ______

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Please provide us with an example of how your program has enhanced the life of a child, or will enhance the life of a child if put into place. ______

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Please email, fax and/or mail this information to:

Helen Lavorata

Director, National Office

Greek Orthodox Ladies Philoptochos Society, Inc.

7 West 55th Street – 7th Floor

New York, NY 10019

(email)

212-977-7770 (office phone)

212-977-7784 (office fax)

If you have any questions, please contact:

Mrs. Rosemary Nikas

Metropolis of Pittsburgh

Philoptochos President

87 Walker Road

Canonsburg, PA 15317

(email)

724-745-5799 (home phone)

724-263-9843 (cell phone)