St. Rita’s Medical Center
Application for Community Investment


Community Investment On-line Policy

Organizations requesting funding support must complete this application form (located at StRitas.org).

Thank you for the work you already do in our community.

CONTACT INFORMATION
Official name of organization:
Non-profit status:
Mailing address: (If PO Box) Physical Address:
Address:
City:
State:
Zip:
Name of person submitting application:
First Name:
Last Name:
Role in the organization:
Phone Number:
Email Address:
Under which identified area of focus should this request be considered?



Please describe your request for funding:
1.
Please provide an event/project summary, along with date(s), audience demographics and community impact.
2.
Does this service/ program already exist in the community? If so, have you collaborated with the others involved to eliminate duplication? How?
3.
How will you measure success of this projector program?
4.
What is the amount of your request?
Additional required information
1.
What is your organization’s mission statement?
2.
Please provide a list of board members, indicate if St. Rita’s employees.
3.
Please provide list of other supporting/ sponsoring organizations.
In addition with the organization’s application, organizations seeking support must provide:
A copy of the organization’s W-9 Form

A copy of the organization’s IRS tax exemption determination letter