2015 Organizational Fellowship Application
Before beginning, please note that submitting this application indicates that 1) the information presented in this
application is correct, and 2) the applicant organization agrees to obtain release time necessary to pursue the
Fellowship program through completion.
Please note the character limits for each question.
Primary Contact Information for Organizational Fellowship Applicant
First Name
Middle Initial
Last Name
Title
E-mail
Phone
Extension
Request Amount
$10,000
Organization Information
Organization Name (Per IRS Designation)
Business Address Line 1
Address Line 2
City
State
Zip Code
Phone
Fax
Web Site
Employer Identification Number
PA Bureau of Charitable Organizations Registration Number
BCO expiration date
If exempt from BCO, state reason. (25 word limit)
Does your organization have a board conflict of interest policy?
Application Questions
Concisely answer these questions. (Note the Character Limits).
Program Name
Please Enter "Organizational Fellowship for Applicant Name;" for example, "Organizational Fellowship for ABC Org, Inc."
Organizational Fellowship for
Mission
Provide a brief summary of your organization’s mission in the community. (500 character limit)
Question 1
Describe your organization’s greatest challenge and why it is a challenge. (2000 character limit)
Question 2
If your organization’s challenge is addressed, how would this change your impact within the community? (2000 character
limit)
Question 3
What does your organization bring to the Organizational Fellowship’s cohort make up? (1500 character limit) (Note: The
cohort is the term we use for the group of organizations that will participate in the Organizational Fellowship program).
To submit your application, send the following attachments to
frodriguez@lancfound.org no later than April 2, 2015:
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This application form (in Word format)
Audit or reviewed financial statement (independent CPA, within 12
months)
Current organization board roster
Current organization budget
Letter of recommendation from board chair