Instructions

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Instructions
1.Save form to your computer.
2.Fill out in Adobe Acrobat and save.
3.Email completed form and additional information to
[email protected]
USA Groundwater Fund Grant Application
Applicant organization name ________________________________________________________________
Applicant’s primary contact information
Name _____________________________________________________ Phone number ________________________
Email address _______________________________________________Website ______________________________
Mailing address____________________________________________________________________________________
____________________________________________________________________________________
Applicant’s type of organization [e.g., 501(c)(3)—attach proof of 501(c)(3) or its equivalent] ______________________
Date of organization’s formation and dates of any change in status __________________________________________
Project information
Type of grant (purpose of funds use):  Groundwater supply project  Education and training program
Project name ______________________________________________________________________________________
Project location ____________________________________________________________________________________
Proposed project start date _________________________ Expected project duration __________________________
Identification and number of individuals the project is expected to directly serve _______________________________
Funding request (in USD) ____________________________________________________________________________
Source of matching funds
Organization name __________________________________Contact name ___________________________________
Phone number ___________________ Email address ________________________ Website _______________________
Conditions on the funds _____________________________________________________________________________
Please fill in the chart below with expenses as a percentage of all funds expensed by your organization.
Expense Category
Administrative
Marketing
2015
2014
2013
Please fill in the chart below with the projection of the total budget, administrative expenses, and marketing expenses for
this project.
Total budget
Administrative
Marketing
Please describe the project and its goal (85 words—621 characters—max).
Please identify potential risks that could result in an uncompleted or unsuccessful project (85 words—621 characters—max).
Please identify individuals who will be performing the work, and attach their credentials and qualifications
(in the form of a resume or CV).
_______________________________________________
________________________________________________
_______________________________________________
________________________________________________
Groundwater supply projects only
Responsible party for ensuring groundwater supply project operation and maintenance for at least five (5) years after
project completion _________________________________________________________________________________
Contact name _____________________________________________________________________________________
Phone number ___________________ Email address ______________________ Website _________________________ Mailing address ____________________________________________________________________________________ ____________________________________________________________________________________
Please describe the means of verifying the project’s operation and maintenance for at least five (5) years after project
completion (85 words—621 characters—max).
References to be contacted about your organization’s previous work of this nature:
Name ____________________________________________________________________________________________
Email ___________________________________________ Phone ____________________________________________
Name ____________________________________________________________________________________________
Email ___________________________________________ Phone ____________________________________________
Have you included:
❑ 501(c)(3) information attached
❑ Pictures of a related project ❑ Resumes or CVs of those performing the work
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