Friends for Life of America

Nearest Chapter:
Name:
Organization:
Address:
City:
State/Province:
Country:
Zip Code:
Phone Number:	- -
Fax Number:	- -
E-Mail Address:
ORGANIZATIONAL INFORMATION
Mission Statement:
Objectives:
Web Site Address:
Are you a 501(c)(3) tax-exempt organization?
What percent of your funds are spent on administrative salaries and services?
PROGRAM INFORMATION
Please describe the proposed initiative in detail. Provide any information that you feel would help us better evaluate your request.
Amount Requested:	$
REFERENCES Please provide contact information for three associates who are knowledgable about this request. 1. Name:
Address:
City:
State:
Zip Code:
Phone Number:	- -
Title:
2. Name:
Address:
City:
State:
Zip Code:
Phone Number:	- -
Title:
3. Name:
Address:
City:
State:
Zip Code:
Phone Number:	- -
Title:
APPLICANT'S STATEMENT
I certify that the answers given herein are true and complete to the best of my knowledge. I release the rights to any and all photographic material, including film, and computer information Friends for Life of America may wish to utilize for all programming and promotional purposes without obligation to me.
Signature: (Please type your name)
Date: