Concentric

Street Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

501(c)3

Yes

No

Contact Name

First Name

Last Name

Phone Number

(###)

###

####

Name

First Name

Last Name

Date

MM

DD

YYYY

Further Documentation *

By clicking this box, I acknowledge that the completion of this online application begins the application process and that my file will not be reviewed until submission of the following documentation is completed either via mail or electronically. The following documents are required: copy of your 501(c)(3) IRS acknowledgment letter; copy of your financial statements for the last two years; copy of your most recent audit; copy of the project budget; copy of your most recent Form 990; summary of your doctrinal positions; any other information that would be helpful in processing this grant. If you have questions, please contact us.

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Verification *

By clicking this box, I hereby attest the the above information is true and correct to the best of my knowledge. I understand that any false statements may disqualify me from this grant.

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