Date of event, if applicable 
* Organization Name         
* 501(c)(3)                       
* Contact Person Name      
* Contact Person's Title      
* Address:                         
* City:                              
* State:                            Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
* Zip:                               
* Telephone Number       
   Fax Number                   
* E-Mail Address               
* Counties or Areas Served 
* Amount Requested           
* Total Project Cost            

 
Questions:
 
Lori Selissen, Executive
Assistant
 
Phone: 920-490-5309
 
Email:
[email protected]
 

* Please describe the purpose for this contribution request.
  (1500 character limit)

* Describe the project for which funds or services are being sought.
  (1500 character limit)

* Give a brief explanation of your organization, its objectives, population served, and geographic area of service.
  (1500 character limit)

Are any Little Rapids Corporation associates involved in the fund drive? Organization? If yes, provide names.
  (1500 character limit)

 
Please attach any additional supporting documentation.

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