Zoo, Arts & Parks Tier II

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.

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.

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.

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.

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

ZAP Tier II 2015 Application (Requests ≤ $15,000)/2013 Evaluation Page 6