Foundation Request Form | Ag Ventures Alliance

Please fill out the following form for any Foundation Requests.

Applicant Name:*

Applicant's Address*

Street Address Address Line 2 City State ZIP Code

Applicant's Phone*

Contact Person*

Applicant's Email*

Applicant's Website, if applicable*

Type of Corporate Entity*

Requesting Organizations' Tax Status:*

If 501(C)(3) please attach documention:

Amount of Request:*

Provide a Brief Overview of Applicant Organization:*

Please provide a description of the specific activities for which the funds will be used and explain how the proposed activity will meet one or more of the following “focuses” of the AgVA Grant Program: • Programs that meet nutritional, educational or leadership needs of rural youth; • Activities that support the mission and vision outlined in Ag Ventures Alliance’s strategic plan; • Mentoring, training and other programs for young and beginning farmers; • Continuing education and training for existing farmers; • Local events in rural communities that promote agriculture or local foods; and, • Agricultural entrepreneurship education and training.*

Please provide a "Sources and Uses of Funds Statement" that includes all revenue and expenses for the proposal*

Please explain measures that will be taken to assure that the activity is carried out effectively, on time and within budget. Please include a timeline of major events or activities that are to occur.*

Explain how the applicant will "complement" the work of other organizations in the area instead of competing against them.*

(Please include timeline)

If applicable, explain how the program or activity will be self-sustaining after grand period has ended.*

Explain how the proposed activity will benefit AgVA members and their communities and/or have a positive impact on new membership in an area not yet served by AgVA.*

Please provide the names and a short biography of each of the applicant's management and executive officers.*

Please provide the names of each of the applicant's board of director's members.*

Explain how you will provide recognition to AgVA for this grant, e.g. press release(s), promotional pieces, recognition in program, speaker or introduction of a speaker, event booth, etc.*

Signature*

Title of person signing:*

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