Legal Name of organization inquiring

Year Founded (yyyy)

Current Operating Budget

Phone

Contact Name

Contact Title

Email Address

Website

Have you received support in the past from the A.A. Van Elslander Foundation? Have you received support in the past from the A.A. Van Elslander Foundation? Yes No

Grant Year(s) and Amount(s)

Have you requested support in the past from the A.A. Van Elslander Foundation and been declined? Have you requested support in the past from the A.A. Van Elslander Foundation and been declined? Yes No Don't Know

Have you received support in the past from the Van Elslander Family Foundation? Have you received support in the past from the Van Elslander Family Foundation? Yes No

Grant Year(s) and Amount(s)

Have you requested support in the past from the Van Elslander Family Foundation and been declined? Have you requested support in the past from the Van Elslander Family Foundation and been declined? Yes No Don't Know

Description of Inquiry

Dates of the Project (start date - end date)

Amount Requested

Total Project Cost

Geographic Area Served

Signature

Date

Applicant Title

Applicant Name