William & Charlotte Parks Foundation for Animal Welfare

- SUMMARY STATEMENT -
THIS FORM MUST BE THE FIRST PAGE OF APPLICATION

Amount Requested: $ _________

Do you have a 501(c)3 Tax Status?          YES        NO

Type of Grant: (Please circle choice):

Capital Grant          Project Grant            General Operating Grant              Ph.D./Veterinary Fellowship

Organization Name:

Complete address:

Contact name:

Tel./Fax/Email: T# _______________F#_______________ E____________________

FINANCIAL SUMMARY (YEAR )

Report in U.S. $ or state what other currency is used and provide approximate exchange rate into U.S. $_____________

Assets (total): Revenue (total):

Investments: Expenses (total):

Cash on Hand: Program:

Building/Equipment: Management/Admin:

Are your accounts audited? Yes No (If yes, who is auditor? )________________________________

If a Project or Capital grant, give total project or capital budget: $

BRIEF NARRATIVE OF PROPOSAL:

FUNDING HISTORY

Have you received Park's funding during the past 3 years? If yes, give year(s) and amount(s) below. List other sources and amounts of funding for project(s). Identify as "R" = received or "A" = applied for.

PLEASE SEND SIX COPIES OF THE ENTIRE PROPOSAL
WITHOUT 6 COPIES YOUR APPLICATION WLL NOT BE CONSIDERED!