Monday, October 20, 2008

General grant request form


PFLAG EUGENE/SPRINGFIELD
P.O. BOX 11137 EUGENE, OR 97440
(541) 686-2280
DONATION REQUEST FORM

PFLAG MISSION:


Parents, Families and Friends of Lesbians and Gays (PFLAG) promotes the health and well-being of gay, lesbian, bisexual and transgender persons, their families and friends through: support, to cope with an adverse society; education, to enlighten an ill-informed public; and advocacy, to end discrimination and to secure equal rights. PFLAG provides an opportunity for dialogue about sexual orientation and gender identity, and acts to create a society that is healthy and respectful of human diversity.

DONATION PHILOSOPHY:


We are pleased to help support organizations which are in keeping with our mission statement and to form coalitions with other Human Rights organizations.



What is the name of your organization? ________________________________________

Is it a non-profit organization? ___yes ___no

What is your mission statement? ____________________________________________

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(Attach extra sheet[s] if necessary)

How does your organization fit into our donation philosophy? _________________________

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(Attach extra sheet[s] if necessary)

What donation (amount) are you requesting from our organization? ____________________

How do you plan to use this donation? (Be specific): _______________________________

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(Attach extra sheet[s] if necessary)

What time period do these plans cover? (i.e. school year, fiscal year etc.): ________________

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(Attach extra sheet[s] if necessary)

Are you willing to make a commitment to report back to us at the end of this time period on how our donation was used and the results of your project? ___yes ___no

What is the amount of your annual budget? _____________________________________

Name of your contact person: ______________________________________________

Address ________________________________________________________________________

Phone ________________________________________________________________________

Email ________________________________________________________________________