Application for Financial Assistance Please complete all fields that apply

Is this application from: * Select an option:An IndividualAn Organization Organization Name (leave blank if individual) * Mission Statement (leave blank if individual) How many paid staff do you have? Briefly outline title and role (leave blank if individual) * How many volunteer staff do you have? Briefly outline title and role (leave blank if individual) * What connection if any does your organization have with the Saint John Y Service Club? (leave blank if individual) Contact Name * Mailing Address * City * Province * Postal Code * Amount or Donation requested Date Funds Required

Purpose of Donation (please explain in detail): Who will benefit from this donation: How will you determine success of your project? Has funding been requested from any other organization(s)? * Select an option:YesNo If yes, please list other organizations from whom funding has been requested, and amount requested: Has funding been received from any other organization(s)? * Select an option:YesNo If yes, please list other organizations from whom funding has been received, and amount received: Have you ever received a donation from the Saint John Y Service Club? * Select an option:YesNo Identify ways you will acknowledge and recognize the donation, if received: * Additional comments or questions

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