Roundup Application

WEST CENTRAL ELECTRIC

ROUNDUP FOUNDATION, INC.

APPLICATION FOR DONATION

Please submit additional documents to:

West Central Electric Cooperative, Inc.

Attention: Roundup Foundation

PO Box 452

Higginsville, MO 64037

Documents may also be submitted via fax at 660.584.7949 or via email at kim@wcecoop.com

Questions?

Contact Kim Lewis at 816.565.4942

Organization *

Address *

Contact *

Title *

Phone *

Email *

How did you learn of our Foundation? *

PROJECT DESCRIPTION

Answers may be attached separately if additional space is required.

All information is mandatory for application to be considered for funding.

Project Title *

Project Description *

Amount Requested $ *

Please describe how funds will be used. Be specific. *

Include in the mail an itemized listing of intended funding use. Include dollar amounts. Quotes and photos are encouraged, when appropriate.

If funding is approved, an invoice or statement demonstrating proof of purchase must be received before funds are released.

List other sources of funding for project, if applicable. *

How does your organization measure effectiveness of program(s) and/or use of funds? Be specific. *

WEST CENTRAL ELECTRIC COOPERATIVE MEMBERS SERVED

Number of individuals, families, and/or groups served WITHIN Jackson, Johnson, Lafayette, Pettis, and Saline (within the West Central Electric Cooperative service territory) in the past year *

Specific counties served within *

Number of individuals, families, and/or groups served OUTSIDE OF Jackson, Johnson, Lafayette, *

Specific counties outside of *

FINANCIAL INFORMATION

Funds exempt from payment of income tax? If yes, a copy of organization’s 501(c)(3) must be attached. *

Yes

No

Is the organization’s 501(c)(3) going to be mailed? *

Yes

No

Is a copy of the financial statement(s) going to be mailed? *

Yes

No

REFERENCES

Please list up to three additional organizational contacts, including leadership, volunteers, and/or those directly served or affected by potential funding.

Contact Name 1 *

Title/Role *

Address *

Phone *

Email *

Does the WCE Roundup Foundation have permission to contact this individual? *

Yes

No

Contact Name 2 *

Title/Role *

Address *

Phone *

Email *

Does the WCE Roundup Foundation have permission to contact this individual? *

Yes

No

Contact Name 3 *

Title/Role *

Address *

Phone *

Email *

Does the WCE Roundup Foundation have permission to contact this individual? *

Yes

No

The information contained in this statement is for the sole purpose of obtaining funding from the WCE Roundup Foundation on behalf of the undersigned. Each undersigned understands that the information provided within the application will be used in deciding whether to grant funding, and each undersigned represents and warrants that the information provided is true and complete and that the WCE Roundup Foundation may consider this statement as continuing to be true and correct until a written notice of change is provided. The WCE Roundup Foundation is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.

Incomplete application will NOT be submitted for committee review.

Name of Organization *

Signature of Representative (If school, must be signed by the Principal or Superintendent) (Type name to sign) *

Date *

Month

Day

Year

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