GearUp Grant Questionnaire Step 1 of 4 25% Point of Contact InformationPlease provide the information for the person who we will be primarily contacting for the completion of this service. Name* First Last Telephone*Email* Is the Point of Contact the Executive Director of the organization?* Yes; the Point of Contact is the Executive Director No; the Point of Contact is not the Executive Director Executive Director Contact InformationExecutive Director Name* First Last Executive Director Telephone*Executive Director Email* Executive Director Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Organization InformationName of Organization Applying for Grant (legal name)* Date of Incorporation* MM slash DD slash YYYY EIN Number* Organization Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Organization PhoneOrganization Website Organization Social MediaYou can submit any links you have for your organization's social media. Social Media PlatformSocial Media Link Is the Organization a 501(c)(3)?* Yes No Pending Mission Statement of the Organization*A mission statement defines the organization’s business, its objectives, and its approach to reach those objectives. Why does your organization exist, and why is it important? Vision Statement of the Organization*A vision statement describes the desired future position of the organization. Where does your organization want to be in the future? Core Values of the Organization*Core values should not only represent what the organization stands for, but they should also guide leadership when determining how and where to direct the business. Organization's DEIA Statement (Diversity, Equity, Inclusion and Accessibility)Many grantors are seeking the implementation of an inclusive policy due to the current climate of advancing equity and equality for all. Please share your organization's statement and/or actions to advance diversity, equity, inclusivity, and accessibility. COVID ImplicationsPlease share how COVID-19 has impacted your organization and programming. Grant Funding InformationBrief Summary of program or organization's activities which requires funding*What are your funding objectives?*Objectives should be Specific, Measurable, Attainable, Realistic, and Time-bound. Example: "By the end of year one, provide 125 mothers in the southwest area of Baltimore with a 2-hour training program that will provide health and nutrition information." What community need or problem is the organization planning to address?*Are your services city-wide, county-wide, state-wide, or national?*Select OneCity-wideCounty-wideState-wideNationalPlease upload your current logo.*Max. file size: 512 MB.Please upload your IRS Determination Letter.*Max. file size: 512 MB.Please upload your current Organizational Budget.Max. file size: 512 MB. 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I agree Once the questionnaire is completed we will need to schedule a brief telephone call to get additional information. Please let us know what date and time you would prefer for your appointment. Keep in mind we may need at least 48 hours to confirm an appointment. Also our normal appointment times are Mon-Fri between 10 am and 4 PM Eastern time. Please select the preferred day and time options on the next page and we will contact you back to confirm the appointment:PhoneThis field is for validation purposes and should be left unchanged.
