Pierce Pepin Cares Grant Application Organization Name EIN / Tax ID Number Contact Name Organization Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Contact Email Contact Phone Number Has your organization ever applied for an Operation Round Up grant? Yes No Prior Grants If you answered yes to the previous question: Please provide information about the most recent grant received: date received; amount requested; amount received; and purpose for which grant was requested. Is organization/agency exempt from income status under IRS code 501[c](3)? Yes No Amount requested Purpose of request (specify how funds will be used) List other sources of funding for request described above Leave this field blank
