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E & R Funding Request Form

Please fill out the following form for any Education and Research Contributions Funding Requests.

Note: AgVA reserves the right to publicly disseminate information about this contribution in its newsletters and other promotional materials.

* denotes a required field.

1. Name of Requesting Organization: *

2. Amount of Funding Requested: *

3. Overview of Requesting Organization: *

4. Description of Requested Funding Activities: *

(including timeline)

5. Describe How the Activities will Meet the Funding Criteria: *

6. Describe How the Activities will Meet the Guidelines: *

7. Describe How will the Activities will Meet the Geographic Priorities: *

8. Sources of Funding for the Activities and Uses of Funds: *

Sources, Uses, Name, and Amount

9. Requesting Organization's Executive Officers: *

10a. Requesting Organizations' Tax Status: *

10b. If 501(C)(3) please attach documention.:

(doc,docx,pdf,jpg)

11. Requesting Organization's Contact Information: *

Address, City, St, Zip, Phone, Email

12. Signature: *

Please print name. This will serve as your signature.

13. Title: *