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Thriving Communities
Environmental
Protection Agency Grant - n t al Form
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Organization Name *
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I. Organization Information
If Fiscally Sponsored please list your Fiscal Sponsor and the name of your project
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Brief Description of Applicant Organization
Provide a brief description (100 words or less) of the applicant organization, including
its mission and key ongoing projects and activities in which it is involved
Mailing Address
Country
Select...
Address
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Address Line 2 (optional)
City
State, Province, or Region
Zip or Postal Code
Site Address (if different from above)
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Country
Address
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Select...
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Address Line 2 (optional)
City
State, Province, or Region
Zip or Postal Code
Organization Phone Number
Organization Website
example.com
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Employer Identification Number
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XX-XXXXXXX
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Organization Annual Budget
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Provide Income Statement for most recently completed fiscal year
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https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632
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Year Organization Founded
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II. Contact Information
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How many full-time equivalent employees (FTE) does your
organization employ?
Primary Contact Name
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First Name
Last Name
Individual will be responsible for ongoing reporting and administration of this grant
Primary Contact Title
Primary Contact Phone Number
https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632
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Primary Contact Email
[email protected]
Authorized Person Contact Name
First Name
Individual with signatory authority
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Last Name
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Authorized Contact Phone Number
Authorized Contact Email
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[email protected]
Other Contact Information
III. Project Phase
Which Project Phase are you applying for?
https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632
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Phase I - Assessment for up to $150,000 for a one-year project period
PHASE II - Planning for up to $250,000 for a one to two-year project period
PHASE III - Development for up to $350,000 for a two-year project period
PHASE I - Noncompetitive Fixed Amount Subaward
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I . Environmental Justice Issue(s) to Be Addressed
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Other
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What are the local environmental/public health issue(s) that your
project seeks to assess (Phase I) or address (Phase II and III)?
https://socialandenvironmentalentrepreneurs.submittable.com/forms/initial/edit/36c1bd70-c20b-4a4a-b903-851ecb20f632
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Initial Form Designer
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Other (please describe)
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V. Project Plan, Goals, Outputs, and Outcomes
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Project Plan, Goals, Outputs, and Outcomes
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| File Type | application/pdf |
| File Title | Initial Form Designer |
| Author | Taylor Bayless |
| File Modified | 2024-06-27 |
| File Created | 2024-05-24 |