The Portage Foundation

Name of Organization

Address

City

State

Zip Code

CEO/Exec. Director

Email

Contact Person

Email

Contact Phone

Federal Tax ID#

Project Title

Amount Requested

Mission Statement

Which of the following Portage Foundation Areas of Focus does your request most closely align?

Brief description of the project (including goals and objectives)

Statement of need

Target population (population served)

Collaboration (indicate agencies you will collaborate with and/or coordinate the delivery of services - if any)

Optional : Other supporting information

*Fill as little, or many as needed

Name Printed

Date

*

By submitting this electronic application, I/we certify that I/we reviewed the information and to the best of my/our knowledge it is accurate.

Grant – Application